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.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
Diuresis, or increased urine production, is not a common adverse effect of nalbuphine hydrochloride. This medication is an opioid analgesic used for pain relief during labor.
Choice B rationale
Fever is not a typical adverse effect of nalbuphine hydrochloride. Fever may indicate an infection or other underlying condition that needs to be addressed separately.
Choice C rationale
Diarrhea is not a common adverse effect of nalbuphine hydrochloride. Opioids, including nalbuphine, are more likely to cause constipation rather than diarrhea.
Choice D rationale
Sedation is a known adverse effect of nalbuphine hydrochloride. As an opioid analgesic, it can cause drowsiness and sedation, which is important to monitor in laboring clients to ensure their safety and well-being.
Correct Answer is D
Explanation
Choice A rationale
A temperature of 37.8°C (100°F) 18 hours postpartum is slightly elevated but not necessarily indicative of a serious issue. It may require monitoring but is not the most urgent concern.
Choice B rationale
Abdominal pain during breastfeeding 8 hours postpartum is a common experience due to uterine contractions. While it may cause discomfort, it is not typically an urgent concern.
Choice C rationale
Not having a bowel movement 24 hours postpartum is not uncommon and does not usually require immediate attention. It can be addressed with dietary changes and other interventions.
Choice D rationale
Saturating one perineal pad over 2 hours 6 hours postpartum in a G5P4 client indicates a potential risk of postpartum hemorrhage. This is a more urgent concern that requires immediate assessment and intervention to prevent complications. .
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