A client who is 37 weeks gestation comes to the women's health clinic reporting an excruciating headache.

On examination, the nurse determines the client has an elevated blood pressure.

Which action should the nurse implement next?

Collect a urine sample to screen for protein.

Ask about a history of delivering large babies.

Examine the client for pedal edema.

Establish the frequency of headaches.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Collecting a urine sample to screen for protein is essential as proteinuria is a key indicator of preeclampsia, a condition characterized by high blood pressure and potential organ damage during pregnancy. Early detection is vital to manage the condition and prevent complications.

Choice B rationale

Asking about a history of delivering large babies (macrosomia) is not immediately relevant to the current symptoms of headache and elevated blood pressure, which are more indicative of hypertensive disorders rather than previous birth weights.

Choice C rationale

Examining the client for pedal edema is important but not the immediate priority. While edema can be associated with preeclampsia, the presence of proteinuria and elevated blood pressure are more critical indicators that need to be addressed first.

Choice D rationale

Establishing the frequency of headaches is useful information but not the immediate priority. The combination of an excruciating headache and elevated blood pressure necessitates a more urgent assessment for preeclampsia, starting with a urine sample for protein.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale

Gathering supplies for an IV infusion is essential in many cases but not the priority here. Measuring abdominal circumference helps determine if there is abdominal distention indicating a possible blockage, which could suggest a condition like Hirschsprung's disease. Early detection and appropriate intervention are critical, making it the first action.

Choice B rationale

Preparing for anorectal surgery may be necessary if a diagnosis like Hirschsprung’s disease or imperforate anus is confirmed. However, the initial priority is to assess for signs of abdominal distention by measuring the circumference, providing crucial information for the next steps.

Choice D rationale

Monitoring strict urinary output is important for overall fluid balance and identifying complications related to fluid shifts. However, in this scenario, the priority action is to assess for abdominal distention, a potential sign of a serious underlying condition causing the symptoms observed in the infant.

A. Stops rooting when hungry. B. Opens mouth when food comes her way. C. Awakens once for nighttime feedings. D. Gives up a bottle for a cup.

Correct Answer is B

Explanation

Choice A rationale

Rooting is a reflex that helps a baby find and latch onto the breast or bottle for feeding. While the rooting reflex may diminish as the baby grows, it is not the primary indicator for introducing solid foods. Other developmental milestones are more relevant for this transition.

Choice B rationale

When a baby starts opening their mouth in response to the sight or smell of food, it indicates a readiness to try solid foods. This behavior shows that the baby is interested in and capable of learning to eat from a spoon, which is a key step in the introduction of solids.

Choice C rationale

Awakening once for nighttime feedings is common for infants and does not necessarily indicate readiness for solid foods. Nighttime awakenings can occur for various reasons, including hunger, but other developmental signs should be considered for introducing solids.

Choice D rationale

Giving up a bottle for a cup is a milestone that typically occurs later in infancy or toddlerhood. It is not directly related to the introduction of solid foods, which generally begins around 4 to 6 months of age based on the child's developmental readiness and interest in food.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A client who is 37 weeks gestation comes to the women's health clinic reporting an excruciating headache. On examination, the nurse determines the client has an elevated blood pressure. Which action should the nurse implement next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An infant born 2 days ago has not passed a meconium stool and begins to vomit bilious secretions. Which action should the nurse take first?

Correct Answer is C

Explanation

The mother of a 4-month-old baby girl asks the nurse when she should introduce solid foods to her infant.The mother states, "My mother says I should put rice cereal in the baby's bottle now.”. The nurse should instruct the mother to introduce solid foods when her child exhibits which behavior?

Correct Answer is B

Explanation

A client who is 38 weeks pregnant is concerned her baby might get a communicable disease before any immunizations are given. Which physiological mechanism should the nurse use when responding to the mother's concerns?

Which is the most important assessment for the nurse to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation?

A client who is 37 weeks gestation comes to the women's health clinic reporting an excruciating headache. On examination, the nurse determines the client has an elevated blood pressure. Which action should the nurse implement next?

The healthcare provider prescribes magnesium sulfate 6 grams IV to be infused over 20 minutes for a client with preterm labor. The IV bag contains "Magnesium sulfate 20 grams in dextrose 5% in water 500 mL.”. How many mL/hour should the nurse set the infusion pump? (Enter numerical value only.)

A child who weighs 25 kg receives a prescription for isoniazid 10 mg/kg/day by mouth once a day. The bottle is labeled "isoniazid Oral Solution, USP 50 mg per 5 mL.”. How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

Upon completion of a 14-day antibiotic treatment for bacterial meningitis in an infant, the nurse prepares the family for discharge. Which information should the nurse include?

A mother brings her male preschooler to the clinic because he has had diarrhea, vomiting, and high fevers for the past three days. The child begins to cry and cling to his mother when the nurse enters the examination room. Which action should the nurse implement to get the child to cooperate?

A client who is 37 weeks gestation comes to the women's health clinic reporting an excruciating headache.

On examination, the nurse determines the client has an elevated blood pressure.

Which action should the nurse implement next?