A nurse is reviewing a client's vital signs and notes the following measurements: temperature 98.4° F, heart rate 88 beats/minute, respirations 16 breaths/minute, and blood pressure 167/107 mm Hg. What is the most appropriate nursing action based on these vital signs?

Document the findings and continue routine monitoring.

Administer a prescribed antihypertensive medication.

Notify the healthcare provider immediately.

Increase the frequency of vital sign measurements to every 15 minutes.

Answer and Explanation

The Correct Answer is C

Choice A rationale

A blood pressure of 167/107 mm Hg is classified as severe hypertension. This is an urgent and potentially life-threatening condition that requires immediate attention, not routine monitoring. Documenting the findings is part of the process, but it is insufficient as a standalone action. Delaying intervention could lead to eclampsia, stroke, or other serious complications.

Choice B rationale

Administering a prescribed antihypertensive medication is a likely intervention, but it is not the most appropriate initial nursing action without first notifying the healthcare provider. The nurse must communicate the critical change in the client's status to the provider to receive specific orders for medication, dosage, and subsequent monitoring based on the clinical picture.

Choice C rationale

A blood pressure of 167/107 mm Hg is indicative of a hypertensive crisis. The most appropriate and immediate nursing action is to notify the healthcare provider. This allows for a timely, coordinated response, including the potential for medication orders, further diagnostic tests, and a change in the plan of care to prevent an eclamptic seizure, stroke, or other end-organ damage.

Choice D rationale

While increasing the frequency of vital sign measurements is an important part of managing severe hypertension, it is not the most appropriate initial action. The primary action is to notify the healthcare provider. The provider will then likely order more frequent monitoring. The nurse must first report the critical finding to initiate the appropriate medical response.

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Correct Answer is B

Explanation

Choice A rationale

Weighing and measuring the newborn is a routine procedure to establish baseline data. However, it is not the most critical intervention in this scenario given the signs of neurological irritability and instability. While important, it does not address the underlying potential cause of the newborn's symptoms.

Choice B rationale

The newborn's symptoms of tremulousness, tachycardia, and hypertension are classic signs of neonatal abstinence syndrome, often associated with in-utero drug exposure, specifically cocaine. Cocaine is a potent CNS stimulant. Obtaining a drug screen is essential to confirm the diagnosis and guide appropriate medical management and supportive care.

Choice C rationale

Assessing neonatal reflexes is a standard part of a neurological assessment. However, the signs of CNS hyperexcitability like tremulousness are already evident. While a good general practice, it is not the most critical action to identify the underlying cause of the severe symptoms and to begin the correct treatment.

Choice D rationale

A gestational age assessment is a standard part of a newborn's physical examination. It helps in classifying the newborn as term, preterm, or post-term. However, the most immediate priority is to identify the cause of the newborn's distress and instability, which is likely related to drug exposure, not gestational age.

A. Fingerstick hemoglobin. B. Urine for protein. C. Lung sounds. D. Deep tendon reflexes. E. Perineal assessment. F. Skin turgor. G. Vision test.

Correct Answer is ["B","D","G"]

Explanation

Choice A (Fingerstick hemoglobin): Assesses anemia, which is not directly related to preeclampsia. While postpartum anemia can occur, the client’s symptoms point toward hypertensive complications, not anemia.
Choice B (Urine protein): Proteinuria is a hallmark sign of preeclampsia. It reflects renal involvement and endothelial damage, making this a critical assessment.
Choice C (Lung sounds): Pulmonary edema can occur with severe preeclampsia, so lung assessment is important. However, it is supportive rather than one of the top four essential diagnostic assessments.
Choice D (DTRs): Hyperreflexia indicates central nervous system irritability and risk for seizures (eclampsia). This is a key focused assessment.
Choice E (Perineal assessment): Important for postpartum care but unrelated to preeclampsia. Not a priority for the suspected diagnosis.
Choice F (Skin turgor): Assesses hydration status. Preeclampsia is not primarily a fluid deficit disorder, so this is not relevant.
Choice G (Vision test): Visual disturbances are classic signs of preeclampsia due to cerebral vasospasm and retinal changes. This is a priority assessment.

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A nurse is reviewing a client's vital signs and notes the following measurements: temperature 98.4° F, heart rate 88 beats/minute, respirations 16 breaths/minute, and blood pressure 167/107 mm Hg. What is the most appropriate nursing action based on these vital signs?

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Naxlex Comprehensive Predictor Exams

The nurse is assessing a newborn who was precipitously delivered at 38-weeks gestation. The newborn is tremulous, tachycardic, and hypertensive. Which assessment action is most important for the nurse to implement?

Correct Answer is B

Explanation

Correct Answer is ["B","D","G"]

Explanation

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