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 C
Explanation
Choice A rationale
Applying lotion to the newborn’s extremities every 8 hours is not recommended during phototherapy. Lotions and ointments can cause burns when exposed to phototherapy lights and may interfere with the treatment’s effectiveness.
Choice B rationale
Repositioning the newborn every 4 hours is not frequent enough. The newborn should be repositioned every 2 hours to ensure even exposure to the phototherapy light and to prevent pressure sores.
Choice C rationale
Removing the eye mask during feedings is correct. The eye mask should be removed during feedings to allow for bonding and to check for any signs of irritation or infection. This also ensures that the newborn’s eyes are protected from the phototherapy light when not under the lamp.
Choice D rationale
Supplementing feedings with glucose water is not recommended. Breast milk or formula should be used to ensure the newborn receives adequate nutrition and hydration. Glucose water does not provide the necessary nutrients and can interfere with breastfeeding.
Correct Answer is []
Explanation
Based on the provided information,
Most Likely Potential Condition
- A. Placenta previa
Actions to Take
- A. Reinforce with the client to maintain bed rest
- C. Insert a large bore intravenous catheter
Parameters to Monitor
- B. Fetal well-being
- D. Vaginal bleeding
Explanation of Other Conditions
- Abruptio placentae:
- Reasoning: This condition typically presents with painful bleeding and a tender, rigid abdomen, which is not consistent with the client’s symptoms of painless, bright red bleeding and a soft, non-tender abdomen.
- Preterm labor:
- Reasoning: The client shows no signs of labor, such as uterine contractions or cervical dilation. The bleeding is also bright red and painless, which is more indicative of placenta previa.
- Cervical insufficiency:
- Reasoning: This condition usually involves painless cervical dilation and effacement without contractions, leading to preterm birth. The client’s cervix is not dilated, and there are no signs of labor, making this condition less likely.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.