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.

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Correct Answer is A

Explanation

Choice A rationale

A sore throat, often due to Streptococcus pyogenes, is a significant precursor to acute rheumatic fever. The body’s immune response to the infection can attack its own tissues, leading to rheumatic heart disease if untreated.

Choice B rationale

Influenza is a viral infection and does not typically lead to acute rheumatic fever. While it can cause significant illness, its mechanism and sequelae are unrelated to those of rheumatic fever.

Choice C rationale

Chickenpox, caused by the varicella-zoster virus, presents with distinct symptoms like a vesicular rash and is not linked to rheumatic fever. It primarily affects the skin and nervous system, not the heart.

Choice D rationale

Mumps, a viral infection, mainly impacts the salivary glands and sometimes the pancreas and testes but is not associated with rheumatic fever. Its pathology differs from the immune-mediated damage seen in rheumatic fever.

A. Maternal blood pressure. B. Level of pain sensation. C. Station of presenting part. D. Variability of fetal heart rate.

Correct Answer is A

Explanation

Choice A rationale

Maternal blood pressure is crucial to monitor post-epidural anesthesia, as hypotension is a common side effect. Prompt detection and management of low blood pressure are vital to ensuring maternal and fetal well-being, making this the most important assessment.

Choice B rationale

Monitoring pain sensation helps determine the effectiveness of the epidural and the level of anesthesia. However, it is secondary to monitoring for hypotension, which can have more immediate and severe consequences.

Choice C rationale

The station of the presenting part is important for labor progression assessment but not as critical as monitoring for hypotension, which can significantly impact both the mother and fetus.

Choice D rationale

Fetal heart rate variability is vital, but immediate maternal hypotension management takes precedence, as it directly affects fetal oxygenation. .

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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

A 7-year-old child is admitted to the hospital with a diagnosis of acute rheumatic fever. In obtaining a health history from the child's mother, the recent occurrence of which illness is most significant?

Correct Answer is A

Explanation

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?

Correct Answer is A

Explanation

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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?