A nurse is caring for a client with gestational hypertension who reports chest pain and shortness of breath.
What should the nurse do first?
Administer oxygen
Assess blood pressure
Assess for visual disturbances
Assess for proteinuria
The Correct Answer is A
The correct answer is choice A. Administer oxygen.
The client is experiencing signs of pulmonary edema, which is a complication of gestational hypertension.
Oxygen therapy can help improve oxygenation and reduce the workload of the heart.
The nurse should also monitor the client’s vital signs, urine output, and magnesium sulfate level.
Choice B. Assess blood pressure.
This is an important action, but not the first priority.
The nurse should assess blood pressure after administering oxygen and stabilizing the client.
Choice C. Assess for visual disturbances.
This is a symptom of severe preeclampsia, but not an immediate threat to the client’s life.
The nurse should assess for visual disturbances as part of the ongoing evaluation of the client’s condition.
Choice D. Assess for proteinuria.
This is a diagnostic criterion for preeclampsia, but not a priority action in this situation.
The nurse should assess for proteinuria as part of the routine urinalysis.
Normal ranges for blood pressure are less than 140/90 mm Hg, and for proteinuria are less than 300 mg/24 hours.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. Administer oxygen.
The client is experiencing signs of pulmonary edema, which is a complication of gestational hypertension.
Oxygen therapy can help improve oxygenation and reduce the workload of the heart.
The nurse should also monitor the client’s vital signs, urine output, and magnesium sulfate level.
Choice B. Assess blood pressure.
This is an important action, but not the first priority.
The nurse should assess blood pressure after administering oxygen and stabilizing the client.
Choice C. Assess for visual disturbances.
This is a symptom of severe preeclampsia, but not an immediate threat to the client’s life.
The nurse should assess for visual disturbances as part of the ongoing evaluation of the client’s condition.
Choice D. Assess for proteinuria.
This is a diagnostic criterion for preeclampsia, but not a priority action in this situation.
The nurse should assess for proteinuria as part of the routine urinalysis.
Normal ranges for blood pressure are less than 140/90 mm Hg, and for proteinuria are less than 300 mg/24 hours.
Correct Answer is B
Explanation
The correct answer is choice B. Assess blood pressure.The nurse should first assess the client’s blood pressure because gestational hypertension is a condition that causes high blood pressure after 20 weeks of pregnancyand can lead to complications such as preeclampsia and abruptio placentae.High blood pressure is a classic sign of preeclampsia, along with proteinuria, edema, headache and blurred vision.
Therefore, the nurse should monitor the client’s blood pressure closely and report any abnormal findings to the health care provider.
Choice A is wrong because administering acetaminophen is not indicated for gestational hypertension and may mask signs of infection or inflammation.
Choice C is wrong because assessing for visual disturbances is not the priority action for gestational hypertension.
Visual disturbances are a symptom of severe preeclampsia or eclampsia, which are more serious conditions that require immediate medical attention.
Choice D is wrong because assessing for proteinuria is not the first action for gestational hypertension.
Proteinuria is a sign of preeclampsia, which may develop from gestational hypertension, but it is not present in all cases.
The nurse should first assess the blood pressure and then check for proteinuria if indicated by the provider or protocol.
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