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
The correct answer is Choice A
Choice A rationale: Using a breast pump helps maintain milk supply and prevent milk stasis, which reduces the risk of developing mastitis. Mastitis is an infection of the breast tissue that can cause pain, swelling, warmth, and redness.
Choice B rationale: Covering breasts immediately after feedings does not directly prevent mastitis. Proper hygiene and ensuring complete breast emptying are more effective measures for preventing mastitis. Covering may trap moisture and bacteria, potentially leading to infection.
Choice C rationale: Wearing an underwire bra between feedings can restrict milk flow and cause clogged ducts, increasing the risk of mastitis. Non-restrictive, well-fitting bras are recommended to ensure proper milk drainage and breast comfort.
Choice D rationale: Washing nipples with soap and water daily can strip natural oils, causing dryness and cracks. Cracked nipples are entry points for bacteria, increasing mastitis risk. Instead, cleaning with plain water is recommended to maintain nipple integrity.
Correct Answer is D
Explanation
Choice A rationale
Assessing the client’s socioeconomic status is important but not the primary action the nurse should take in the maternal newborn unit. The focus should be on providing unbiased teachings based on the client’s needs.
Choice B rationale
Collecting a dietary history is important but not the primary action the nurse should take in the maternal newborn unit. The focus should be on providing unbiased teachings based on the client’s needs.
Choice C rationale
Determining the best method of contraception for the client is important but not the primary action the nurse should take in the maternal newborn unit. The focus should be on providing unbiased teachings based on the client’s needs.
Choice D rationale
Performing unbiased teachings based on the client’s needs is the primary action the nurse should take in the maternal newborn unit. This ensures that the client receives accurate and relevant information tailored to their specific situation.
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