A nurse is caring for a 26-year-old primigravida female client who is at 28 weeks of gestation in the maternity ward. The client is obese and has no history of hypertension or diabetes mellitus. She presents with elevated blood pressure, peripheral edema, and headaches.
Complete the following sentence by using the list of options. The nurse should first address the client’s
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}
The nurse should first address the client’s A. Elevated blood pressure, followed by the client’s D. Visual disturbances.
Explanation:
- Elevated blood pressure: This is the most critical issue to address first because it poses an immediate risk to both the mother and the fetus. Severe hypertension can lead to complications such as preeclampsia, eclampsia, or placental abruption. The provider has already prescribed labetalol to manage the blood pressure, which is a priority intervention.
- Visual disturbances: These can be a sign of worsening preeclampsia, which requires close monitoring and prompt intervention. Addressing visual disturbances is crucial to prevent further complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Warming the newborn’s heel for 5 to 10 minutes before the puncture increases blood flow, making it easier to collect a blood sample.
Choice B rationale
The outer aspect of the heel is the recommended site for puncture to avoid injury to the bone and nerves.
Choice C rationale
Leaving the heel open to the air after the puncture is not recommended as it can increase the risk of infection.
Choice D rationale
Applying an antiseptic after collecting the specimen is not necessary and can interfere with the blood sample.
Correct Answer is A
Explanation
Choice A rationale
Checking the identity of individuals who come to remove the baby from the room is crucial for preventing infant abduction and ensuring the safety of the newborn.
Choice B rationale
Matching the bracelet on the baby with the footprint record each shift is not a standard practice for newborn identification and safety.
Choice C rationale
Scanning the baby’s identification bracelet each time they are checked on is not a common practice and may not be feasible.
Choice D rationale
Wearing an electronic bracelet when out of the room is a safety measure, but it does not replace the need for parents to verify the identity of individuals handling their baby. .
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