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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Passive immunity provided by maternal antibodies crossing the placenta and through breast milk protects newborns in the first months of life, offering initial defense against communicable diseases.
Choice B rationale
Antiinfectants effectiveness against microbes does not apply; newborns rely on passive immunity as their adaptive immune system matures, not unresistant antiinfectants.
Choice C rationale
Active immunity develops over several months to years in newborns, as their immune system gradually encounters pathogens and develops specific responses.
Choice D rationale
While neutrophils are part of the innate immune system, they may still be immature and insufficient in preventing infections in neonates without maternal antibody support.
Correct Answer is C
Explanation
Choice A rationale
Caput succedaneum is a benign, self-limiting condition and does not require direct pressure. It resolves on its own within a few days after birth. Applying pressure may cause unnecessary discomfort to the newborn.
Choice B rationale
A STAT CT scan of the head is not necessary for diagnosing cephalhematoma, which is a localized collection of blood between the skull and periosteum. CT scans are typically reserved for more severe neurological concerns.
Choice C rationale
A cephalhematoma, characterized by swelling that does not cross suture lines, requires notification of the pediatrician. It may increase the risk of hyperbilirubinemia and needs monitoring for potential complications.
Choice D rationale
While assessing neurological vital signs every 4 hours is important for overall newborn care, it does not address the specific condition of cephalhematoma. The primary concern is monitoring for complications such as jaundice.
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