A nurse is assisting in the care of a client at 30 weeks of gestation who has a blood pressure reading of 160/116 mm Hg and 4 hours previously it was 164/114 mm Hg. The client reports blurred vision and a persistent frontal headache.
Which of the following complications of gestation should the nurse suspect?
Gestational hypertension.
Preeclampsia with severe features.
Preeclampsia without severe features.
Chronic hypertension.
The Correct Answer is B
Choice A rationale
Gestational hypertension is diagnosed when high blood pressure develops after 20 weeks of pregnancy without other symptoms of preeclampsia, such as proteinuria or end-organ dysfunction.
Choice B rationale
Preeclampsia with severe features includes high blood pressure, proteinuria, and symptoms like blurred vision and headaches. These indicate severe disease, which can endanger both the mother and the fetus if left untreated.
Choice C rationale
Preeclampsia without severe features involves high blood pressure and proteinuria but without the additional severe symptoms like blurred vision and headache.
Choice D rationale
Chronic hypertension refers to high blood pressure that was present before pregnancy or diagnosed before 20 weeks of gestation. It does not typically present with acute symptoms like blurred vision and headache that develop suddenly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The primary role of the nurse in genetic counseling is to provide support and answer any Questions the client may have, helping them to understand the information and make informed decisions.
Choice B rationale
While discussing testing risks and benefits is important, it is usually the role of the genetic counselor or physician to explain these aspects comprehensively. The nurse supports this process but does not typically lead it.
Choice C rationale
Performing tests and analyzing results are tasks that are typically carried out by specialized laboratory personnel or geneticists, not the nurse. The nurse's role is supportive rather than diagnostic.
Choice D rationale
The nurse may assist during a provider's consult, but this is not the primary role. The main role focuses on supporting the client through the counseling process and ensuring they understand and can make informed decisions.
Correct Answer is B
Explanation
Choice A rationale
Feeding the newborn water during the procedure is incorrect because water does not provide effective pain relief during procedures.
Choice B rationale
Placing the newborn's arms and legs in flexion and close to the midline of the torso is correct as this position, known as facilitated tucking, provides comfort and can help reduce pain.
Choice C rationale
Placing the newborn supine during the procedure is incorrect because it does not provide any specific pain relief benefits.
Choice D rationale
Elevating the newborn's head during the procedure is not specifically related to pain relief but is more about positioning for ease of access. .
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