A primigravida client who is at 33 weeks gestation presents to the labor and delivery unit troubled with a headache. The initial assessment findings include a blood pressure of 144/96 mm Hg, facial edema, and 3+ pitting edema in lower extremities. Which assessment should the nurse perform next?

Intensity of pain with contraction.

Fetal heart rate.

Temperature, pulse, and respirations.

Deep tendon reflexes and clonus.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Assessing pain intensity with contraction is not the priority when preeclampsia is suspected. The client's headache, hypertension, and edema indicate a need to evaluate for more specific signs of preeclampsia.

Choice B rationale

Fetal heart rate assessment is important, but evaluating maternal status is more urgent when preeclampsia symptoms are present. Monitoring maternal indicators helps determine the severity of preeclampsia.

Choice C rationale

Checking temperature, pulse, and respirations is part of routine assessment, but it does not provide specific information related to preeclampsia. Other assessments are more relevant for the client's condition.

Choice D rationale

Assessing deep tendon reflexes and clonus helps identify severe preeclampsia and potential for eclampsia. Hyperreflexia and clonus are signs of central nervous system irritability, requiring immediate attention and intervention.

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Correct Answer is C

Explanation

Choice A rationale

Glucose water may be soothing due to the sweet taste, but it does not address the immediate need to protect the circumcision site from infection and aid in healing.

Choice B rationale

Liquid acetaminophen provides pain relief, but it does not address the immediate need to protect the circumcision site. Pain management alone is not sufficient for postoperative care.

Choice C rationale

Applying petrolatum gauze dressings on the site prevents the wound from sticking to the diaper, reduces irritation, and protects against infection, promoting healing. This is a priority intervention post-circumcision.

Choice D rationale

While keeping the infant warm is important for comfort and stability, it does not directly address the need to care for the circumcision site to prevent complications and promote healing.

A. You will need to set up an appointment with your obstetrician in 8 weeks. B. You will need to abstain from sexual activities until you see your obstetrician. C. Contact the pediatrician if the baby is not breastfeeding well or has fewer wet diapers and stools. D. The lactation nurse will be coming by to work with you and your baby.

Correct Answer is C

Explanation

Choice A rationale

The obstetrician follow-up appointment is typically scheduled at 6 weeks postpartum, not 8 weeks. Accurate timing of follow-up visits is crucial for monitoring the mother's health and recovery.

Choice B rationale

While abstaining from sexual activities postpartum is generally advised, it is usually recommended until the 6-week follow-up appointment, not specified by the obstetrician's discretion.

Choice C rationale

Contacting the pediatrician if the baby is not breastfeeding well or has fewer wet diapers and stools is critical for early detection of feeding issues, dehydration, or other health concerns.

Choice D rationale

A lactation nurse visit is beneficial for breastfeeding support but does not cover the broader scope of postpartum care and monitoring the newborn's health. Comprehensive instructions are essential for new mothers.

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A primigravida client who is at 33 weeks gestation presents to the labor and delivery unit troubled with a headache. The initial assessment findings include a blood pressure of 144/96 mm Hg, facial edema, and 3+ pitting edema in lower extremities. Which assessment should the nurse perform next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The parents of a male newborn have signed an informed consent for circumcision. Which priority intervention should the nurse implement upon completion of the circumcision?

Correct Answer is C

Explanation

What instructions should the nurse provide to a new mother regarding postpartum care and monitoring the newborn’s health?

Correct Answer is C

Explanation

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