A client at 8-weeks gestation has a hemoglobin of 9.5 g/dl (5.9 mmol/L). Which nursing intervention has the highest priority?

Reference Range:

Hemoglobin (Hgb) [Pregnant female: greater than 11 g/dL (110 g/L)

Instruct the client to add citrus fruits to diet.

Explain this is expected in early pregnancy.

Obtain an iron supplement prescription.

Recommend increasing dietary iron-rich foods.

Answer and Explanation

The Correct Answer is C

A. Instruct the client to add citrus fruits to diet: While vitamin C helps with iron absorption, the primary concern here is the client's low hemoglobin, which requires iron supplementation to address the anemia.

B. Explain this is expected in early pregnancy: While mild anemia can occur during pregnancy, a hemoglobin of 9.5 g/dL is lower than the recommended threshold and requires intervention beyond reassurance.

C. Obtain an iron supplement prescription: The client's hemoglobin is below the expected range for pregnancy (greater than 11 g/dL), indicating anemia that requires iron supplementation to increase red blood cell production and improve oxygen delivery.

D. Recommend increasing dietary iron-rich foods: While dietary changes are beneficial, the priority should be initiating iron supplementation to address the anemia more effectively and quickly.

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Correct Answer is C

Explanation

A. A primiparous adolescent living at home with her parents and significant other: While being a young, first-time mother may pose challenges, the support system of living with parents and a significant other may help mitigate psychological risks.

B. A multiparous female with a large family living in the community: A woman with multiple children and a support system in the community is less likely to experience significant psychological difficulties, as she may be more experienced and have more resources to draw from.

C. A primiparous woman who has recently immigrated to the U.S. with her spouse: This woman is at high risk for psychological difficulties, such as postpartum depression, due to potential isolation, lack of support, cultural differences, and challenges adjusting to a new environment without an extended support network.

D. A multiparous client who lives with her husband and his family members: While living with extended family can sometimes present stress, this client has a support system, including both her husband and family members, which may help reduce the risk of psychological difficulties.

A. Palpate the abdomen for uterine enlargement. B. Observe the appearance of the bleeding on the client's pad. C. Measure the client's vital signs. D. Obtain a history of the exact length of each cycle.

Correct Answer is C

Explanation

A. Palpate the abdomen for uterine enlargement: While abdominal palpation may reveal uterine enlargement, it is not the first priority. The nurse needs to assess the client’s current clinical status to determine if there is any immediate risk of complications like hemorrhage.
B. Observe the appearance of the bleeding on the client's pad: Observing the appearance of the bleeding is important for understanding the severity of the condition, but the nurse should first assess the client's vital signs to identify any signs of hemodynamic instability or shock.
C. Measure the client's vital signs: The most immediate assessment is to check the client’s vital signs, especially if the increased bleeding has caused any changes in her hemodynamic status. This step will help determine if the client is experiencing a serious complication such as hypovolemic shock.
D. Obtain a history of the exact length of each cycle: While obtaining a detailed history is helpful, it is not the first action. Vital signs should be checked first to ensure that the client is stable before gathering additional information.

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A client at 8-weeks gestation has a hemoglobin of 9.5 g/dl (5.9 mmol/L). Which nursing intervention has the highest priority? Reference Range: Hemoglobin (Hgb) [Pregnant female: greater than 11 g/dL (110 g/L)

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

A client at 8-weeks gestation has a hemoglobin of 9.5 g/dl (5.9 mmol/L). Which nursing intervention has the highest priority? Reference Range: Hemoglobin (Hgb) [Pregnant female: greater than 11 g/dL (110 g/L)

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A client at 8-weeks gestation has a hemoglobin of 9.5 g/dl (5.9 mmol/L). Which nursing intervention has the highest priority?

Reference Range:

Hemoglobin (Hgb) [Pregnant female: greater than 11 g/dL (110 g/L)