A nurse is caring for a client during an initial prenatal visit.
The client's last menstrual period was 18 weeks ago.
Which of the following actions should the nurse plan to take?
Obtain the client's personal and family medical history.
Obtain information about prior pregnancies.
Check the client's urine with a reagent strip.
Schedule the client for prenatal laboratory testing.
Discuss chorionic villus sampling with the client.
The Correct Answer is A
Choice A rationale
Obtaining the client's personal and family medical history is essential during the initial prenatal visit. This history helps identify any genetic disorders or chronic conditions that might affect the pregnancy. It also provides insight into the client's overall health and any potential risk factors.
Choice B rationale
Information about prior pregnancies is important but not the first priority. Prior pregnancy information can provide insights into previous complications, but a comprehensive medical history should come first.
Choice C rationale
Checking the client's urine with a reagent strip is not the primary action during an initial visit. Urine tests are useful for detecting infections and certain conditions, but they come after a thorough history has been obtained.
Choice D rationale
Scheduling the client for prenatal laboratory testing is necessary, but it follows the initial assessment and history-taking. Laboratory tests help confirm the pregnancy and assess overall health but are not the first step.
Choice E rationale
Discussing chorionic villus sampling (CVS) is premature at this stage. CVS is a prenatal test conducted around 10-13 weeks for detecting chromosomal abnormalities, but it's not relevant during the initial visit without understanding the client's medical history.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"A"},"E":{"answers":"A"}}
Explanation
Weight loss of 2.8 kg (6.2 lb): Consistent - Significant weight loss is a classic symptom of hyperemesis gravidarum. The client has lost more than 5% of her pre-pregnancy weight, which is concerning and supports this diagnosis.
Hematocrit: 30%: Not Consistent - Hematocrit measures the proportion of red blood cells in the blood. In hyperemesis gravidarum, the hematocrit may be elevated due to dehydration, not decreased. Therefore, this value is not consistent with the typical presentation.
Vaginal spotting: Not Relevant - While vaginal spotting can be concerning in pregnancy, it is not a specific sign of hyperemesis gravidarum and does not directly relate to the diagnosis of severe nausea and vomiting.
Heart rate: 110/min: Consistent - Tachycardia (elevated heart rate) can occur due to dehydration and the body’s response to prolonged vomiting, making this finding consistent with hyperemesis gravidarum.
BUN: 28 mg/dL: Consistent - Blood urea nitrogen (BUN) is elevated in this client, suggesting dehydration. Dehydration is a common complication of hyperemesis gravidarum due to persistent vomiting and poor oral intake.
Correct Answer is A
Explanation
Choice A rationale
Obtaining the client's personal and family medical history is essential during the initial prenatal visit. This history helps identify any genetic disorders or chronic conditions that might affect the pregnancy. It also provides insight into the client's overall health and any potential risk factors.
Choice B rationale
Information about prior pregnancies is important but not the first priority. Prior pregnancy information can provide insights into previous complications, but a comprehensive medical history should come first.
Choice C rationale
Checking the client's urine with a reagent strip is not the primary action during an initial visit. Urine tests are useful for detecting infections and certain conditions, but they come after a thorough history has been obtained.
Choice D rationale
Scheduling the client for prenatal laboratory testing is necessary, but it follows the initial assessment and history-taking. Laboratory tests help confirm the pregnancy and assess overall health but are not the first step.
Choice E rationale
Discussing chorionic villus sampling (CVS) is premature at this stage. CVS is a prenatal test conducted around 10-13 weeks for detecting chromosomal abnormalities, but it's not relevant during the initial visit without understanding the client's medical history.
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