During a prenatal visit, a client at 30 weeks gestation reports persistent heartburn during the past two weeks.
The nurse notes the client has 3+ bilateral, pitting, pedal edema.
Which action should the nurse implement?

Explain that heartburn is a common discomfort.

Ask if blurred vision and headache have occurred.

Check urine for presence of glucose and ketones.

Instruct the client to take an antacid as needed.

Answer and Explanation

The Correct Answer is B

Choice A rationale

While heartburn is common during pregnancy due to hormonal changes and pressure from the growing uterus, the presence of 3+ bilateral pitting pedal edema raises concerns. This symptom could indicate a more serious condition, such as preeclampsia, and should not be dismissed as a normal discomfort.

Choice B rationale

Asking if blurred vision and headache have occurred is essential because these symptoms, along with significant edema, are indicators of preeclampsia. Preeclampsia is a serious pregnancy complication characterized by high blood pressure and damage to other organ systems, often requiring immediate medical attention.

Choice C rationale

Checking urine for glucose and ketones is relevant for assessing gestational diabetes but does not address the immediate concern of preeclampsia. The symptoms of edema and possible preeclampsia should be prioritized over concerns of gestational diabetes.

Choice D rationale

Instructing the client to take an antacid for heartburn does not address the critical issue of significant edema. While heartburn relief is important, the symptoms of edema need immediate evaluation to rule out preeclampsia or other complications.

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Correct Answer is A

Explanation

Hypoglycemia is a common concern for newborns with low birth weight. Their glucose reserves are limited, and they have a higher metabolic rate, making them prone to low blood sugar levels.

Choice B rationale

Polycythemia, an increased red blood cell count, is not typically a primary concern based on the measurements given. It is more commonly associated with conditions like delayed cord clamping or maternal diabetes.

Choice C rationale

Hyperthermia is not a primary concern based on the provided measurements. Thermoregulation issues might arise, but initial focus should be on managing glucose levels.

Choice D rationale

Hyperbilirubinemia, or jaundice, can occur in newborns but is not the immediate priority based on the given physical findings. Monitoring and managing blood sugar levels is more critical in the initial hours after birth.

A. Perform a vaginal exam. B. Take vital signs. C. Palpate the bladder. D. Examine the amniotic fluid. E. Dipstick urine for protein and ketones.

Correct Answer is ["A","B"]

Explanation

Choice A rationale

Performing a vaginal exam is crucial in assessing the progress of labor and the condition of the cervix, particularly if the client has reported symptoms such as contractions, bleeding, or fluid leakage. It helps determine if the client is in active labor or if there are any complications requiring immediate intervention.

Choice B rationale

Taking vital signs is essential to assess the client's overall health and identify any signs of distress or complications. Vital signs provide critical information about the client's cardiovascular and respiratory status, which is important for immediate clinical decision-making.

Choice C rationale

Palpating the bladder is important in assessing for bladder distention, which can impede labor progress or cause discomfort. However, it is not the immediate priority compared to assessing labor progress and overall health status.

Choice D rationale

Examining the amniotic fluid is important for determining its characteristics, which can provide information about the fetal well-being. However, this action is secondary to performing a vaginal exam and taking vital signs in the immediate assessment.

Choice E rationale

Dipstick urine for protein and ketones helps in assessing for preeclampsia or gestational diabetes, but it does not address the immediate need to assess labor progress and the client's overall health status.

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During a prenatal visit, a client at 30 weeks gestation reports persistent heartburn during the past two weeks.The nurse notes the client has 3+ bilateral, pitting, pedal edema.Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a newborn who is 18 inches long, weighs 4 pounds, 14 ounces (2.2 kg), has a head circumference of 13 inches (33 cm), and a chest circumference of 10 inches (25.4 cm). Based on these physical findings, assessment for which condition has the highest priority?

Correct Answer is A

Explanation

The nurse determines the need to perform further assessment based on the client's situation.Select the 2 actions that the nurse should perform immediately.

Correct Answer is ["A","B"]

Explanation

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During a prenatal visit, a client at 30 weeks gestation reports persistent heartburn during the past two weeks.The nurse notes the client has 3+ bilateral, pitting, pedal edema.Which action should the nurse implement?

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During a prenatal visit, a client at 30 weeks gestation reports persistent heartburn during the past two weeks.
The nurse notes the client has 3+ bilateral, pitting, pedal edema.
Which action should the nurse implement?