A nurse is assessing a client who is pregnant for preeclampsia. Which of the following findings should indicate to the nurse that the client requires further evaluation for this disorder?

Elevated blood pressure

Increased urine output

Joint pain

Vaginal discharge

Answer and Explanation

The Correct Answer is A

Choice A reason: Elevated blood pressure is a hallmark sign of preeclampsia, which is a hypertensive disorder of pregnancy that can cause serious complications, such as eclampsia, HELLP syndrome, or placental abruption. The nurse should monitor the client's blood pressure regularly and report any readings above 140/90 mm Hg to the provider.

Choice B reason: Increased urine output is not a sign of preeclampsia, but rather a normal physiological change of pregnancy, as the renal blood flow and glomerular filtration rate increase. A client with preeclampsia may have decreased urine output, which can indicate renal impairment or oligohydramnios.

Choice C reason: Joint pain is not a sign of preeclampsia, but rather a common discomfort of pregnancy, as the hormones relaxin and progesterone loosen the ligaments and joints. A client with preeclampsia may have epigastric pain, which can indicate liver involvement or impending eclampsia.

Choice D reason: Vaginal discharge is not a sign of preeclampsia, but rather a normal occurrence of pregnancy, as the cervical glands secrete more mucus to protect the uterus from infection. A client with preeclampsia may have vaginal bleeding, which can indicate placental abruption or disseminated intravascular coagulation.

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Correct Answer is A

Explanation

Choice A reason: This action is the first and most important intervention that the nurse should perform, as it can prevent or reduce the compression of the umbilical cord, which can cause fetal hypoxia, bradycardia, or death. The nurse should insert a gloved hand into the vagina and gently push the presenting part away from the cord, and maintain this position until the delivery.

Choice B reason: This action is not the first intervention that the nurse should perform, as it does not address the cause of the cord prolapse, which is the displacement of the cord below the presenting part. However, this action is helpful to prevent the drying and infection of the cord, and should be done after the first intervention.

Choice C reason: This action is not the first intervention that the nurse should perform, as it may not be effective or feasible depending on the stage of labor and the client's condition. However, this action is beneficial to reduce the pressure of the presenting part on the cord, and should be done after the first intervention.

Choice D reason: This action is not the first intervention that the nurse should perform, as it does not provide immediate relief or protection to the fetus. However, this action is necessary to expedite the delivery and prevent further complications, and should be done after the first intervention.

A. Assist the client with transferring to the gynecology unit. B. Offer the mother private time with the newborn. C. Administer alprazolam 0.5 mg PO. D. Contact the health care facility's clergy.

Correct Answer is B

Explanation

Choice A reason: Assisting the client with transferring to the gynecology unit is not the first action that the nurse should take, as it does not address the client's emotional needs or preferences. The nurse should first assess the client's coping and grieving process, and provide support and comfort.

Choice B reason: Offering the mother private time with the newborn is the first action that the nurse should take, as it can facilitate the bonding and closure process, and help the client express her feelings and emotions. The nurse should respect the client's wishes and cultural beliefs regarding the viewing and holding of the stillborn infant, and provide a quiet and private environment.

Choice C reason: Administering alprazolam 0.5 mg PO is not the first action that the nurse should take, as it is a pharmacological intervention that requires a prescription and an assessment of the client's condition and history. The nurse should first use nonpharmacological methods, such as active listening, therapeutic communication, and counseling, to help the client cope and manage her anxiety and grief.

Choice D reason: Contacting the health care facility's clergy is not the first action that the nurse should take, as it may not be appropriate or desired by the client. The nurse should first ask the client if she wants any spiritual or religious support, and respect her decision and beliefs.

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A nurse is assessing a client who is pregnant for preeclampsia. Which of the following findings should indicate to the nurse that the client requires further evaluation for this disorder?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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