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 C

Explanation

Choice A rationale

Jarisch-Herxheimer reaction is seen in spirochete infections like syphilis or Lyme disease, not typically in pelvic inflammatory disease (PID) treated with antibiotics like levofloxacin and metronidazole.

Choice B rationale

Serial anaerobic cultures are not routine for PID management. Diagnosis and management focus more on clinical symptoms and empirical antibiotic therapy rather than continuous culture monitoring.

Choice C rationale

Supervised parenteral antibiotic protocols ensure proper dosage and administration, crucial for severe infections requiring hospitalization. Monitoring treatment in a controlled environment increases effectiveness and reduces complications.

Choice D rationale

While infection control is important, PID typically spreads through sexual contact, and hospital admission for infection control is not the primary reason. The focus is more on effective treatment delivery in severe cases. .

A. Gather supplies for an IV infusion. B. Prepare for anorectal surgery. C. Measure abdominal circumference. D. Monitor strict urinary output.

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.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

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

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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?