A nurse is caring for a client who is at 36 weeks of gestation and reports a headache.
Which of the following actions should the nurse take? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)
Graphic Results Temperature 37° C (98.6° F) Heart rate 88/min Respiratory rate 18/min
Blood pressure 144/94 mm Hg
Upper abdominal pain rating 4/10 on a scale from 0 to 10
Perform a contraction stress test.
Prepare for delivery of the fetus.
Increase the client's dietary salt intake to 2 g/day.
Administer ferrous sulfate to the client.
Upper abdominal pain rating 4/10 on a scale from 0 to 10
The Correct Answer is B
Choice A rationale:
A contraction stress test is not appropriate in this context and would not address the potential risks associated with the client's symptoms.
Choice B rationale:
The elevated blood pressure and upper abdominal pain suggest potential preeclampsia, a serious complication of pregnancy that can lead to significant maternal and fetal risks. Delivery may be indicated to prevent further complications.
Choice C rationale:
Increasing dietary salt intake is not recommended for managing elevated blood pressure in pregnancy.
Choice D rationale:
Administering ferrous sulfate is unrelated to the client's symptoms and concerns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B, A, E, C, D
Explanation
This sequence ensures proper identification, infection control, specimen collection, and safety for the newborn.
Choice A rationale:
The nurse should place a heel warmer on the newborn's heel for 3 to 5 minutes before the heelstick to increase blood flow and facilitate collection.
Choice B rationale:
The nurse should confirm the identity of the newborn before collecting any specimen to ensure patient safety and avoid errors.
Choice C rationale:
The nurse should apply pressure to the puncture site with a dry gauze pad to stop bleeding and promote clotting.
Choice D rationale:
The nurse should label the specimen per facility protocol to ensure accurate identification and processing.
Choice E rationale:
The nurse should clean the puncture site with an antiseptic cleanser to prevent infection and reduce contamination of the specimen.
Correct Answer is B
Explanation
Choice A rationale:
Waiting until school age to engage in social activities is not appropriate, as social interaction is important for a toddler's development.
Choice B rationale:
Interacting with the child according to their developmental age is important for fostering appropriate growth and development.
Choice C rationale:
Devoting more time to learning than playing may not be appropriate, as play is an essential component of early childhood development.
Choice D rationale:
Teaching several steps of a task at one time may be overwhelming for a toddler with a cognitive delay. Instructions should be simple and broken down into manageable steps.
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