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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The client is a 4-month-old female with a history of gastroesophageal reflux (GERD). Client had fundoplication surgery and will be hospitalized for several days of recovery.
Based on the FLACC score and the client's developmental level, mark which nurse actions would be appropriate, and which would not be appropriate.
Each row must have one option selected.
Correct Answer is A
Explanation
Choice A rationale
Projectile vomiting in an infant with an olive-like mass in the abdomen suggests pyloric stenosis. This condition causes severe vomiting due to gastric obstruction. It's a hallmark symptom and requires monitoring and surgical intervention.
Choice B rationale
While arching the back can occur in various conditions, it is not specifically indicative of pyloric stenosis. It could be a sign of discomfort or other neurological issues but not directly related to the gastrointestinal obstruction seen in pyloric stenosis.
Choice C rationale
Frequent pauses during feeding are common in many infant conditions and are not specific to pyloric stenosis. They indicate general feeding difficulties but are not diagnostic of this particular condition.
Choice D rationale
Coffee-ground emesis indicates bleeding in the gastrointestinal tract but is not typical of pyloric stenosis. The hallmark sign is non-bloody, forceful vomiting due to gastric outlet obstruction.
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