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 B

Explanation

Choice A rationale

Starting oxytocin infusion immediately may cause uterine hyperstimulation in clients who have already responded to misoprostol. Close monitoring and spacing out uterotonic agents help prevent adverse effects like uterine tachysystole and fetal distress.

Choice B rationale

Beginning oxytocin 4 hours after misoprostol ensures sufficient time for cervical ripening and reduces the risk of uterine hyperstimulation. This allows for safer labor induction and better outcomes for both mother and fetus.

Choice C rationale

Ambulating the client after misoprostol administration is generally safe but doesn't address the need for controlled uterotonic administration. Monitoring and timing of further uterotonics are crucial to avoid adverse effects and ensure safe induction.

Choice D rationale

Administering misoprostol every 2 hours is not recommended due to the risk of uterine hyperstimulation. It’s important to follow safe dosing intervals to reduce the risk of complications such as uterine tachysystole and fetal compromise.

A. A couple who express concern about birth defects after using an internet DNA testing site. B. A woman and her significant other who are excited about the prospect of having children. C. A woman planning to start a second family after the loss of an embryo following an in-vitro fertilization procedure. D. A man who states that his father was recently diagnosed with Huntington’s disease. E. A couple who plan to use in-vitro fertilization with donated sperm.

Correct Answer is ["A","C","D","E"]

Explanation

The correct answer is Choice A, Choice C, Choice D, Choice E.

Choice A rationale

Genetic counseling is recommended for couples concerned about birth defects to identify any potential genetic abnormalities or risks for inherited conditions.

Choice B rationale

Couples excited about having children do not necessarily require genetic counseling unless there are known risk factors or concerns about genetic conditions.

Choice C rationale

Loss of an embryo following an in-vitro fertilization procedure may indicate underlying genetic issues, warranting further evaluation through genetic counseling.

Choice D rationale

Huntington’s disease is an autosomal dominant disorder; individuals with a family history should seek genetic counseling to assess their risk of inheritance and possible transmission.

Choice E rationale

In-vitro fertilization with donated sperm may involve genetic screening and counseling to ensure the donor's genetic profile is compatible and free of heritable conditions.

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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

A primigravida client with gestational hypertension and a Bishop score of 3 is scheduled for induction of labor. The nurse administers misoprostol at 0700, then observes regular contractions with cervical changes at 0900. Which action should the nurse take?

Correct Answer is B

Explanation

A nurse is conducting a preconception class for a group of parents who are anticipating having children. Which client(s) should the nurse refer for genetic counseling? (Select all that apply)

Correct Answer is ["A","C","D","E"]

Explanation

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