The nurse is concerned about the client's assessment and vitals.
What is the PRIORITY assessment the nurse should perform NEXT?
Urinalysis results.
Assessment of edema.
Neuro assessment.
Assessment of intake and output and skin turgor.
The Correct Answer is C
Choice A rationale
Urinalysis results provide information about renal function and potential infections but are not the immediate priority for a client whose vitals and assessment are concerning. A neuro assessment is the priority to rule out central nervous system changes, which can indicate serious complications such as preeclampsia or eclampsia.
Choice B rationale
Assessment of edema is an important part of a full physical assessment, especially in a pregnant client, but it is not the next priority. While edema can be a sign of preeclampsia, it is a less immediate concern compared to neurological changes.
Choice C rationale
A neuro assessment is the priority because the client's concerning vital signs and assessment findings could be indicative of preeclampsia. Neurological symptoms such as headache, visual disturbances, or altered mental status are critical indicators of central nervous system involvement and potential progression to eclampsia.
Choice D rationale
While assessing intake and output and skin turgor is part of a complete assessment, especially for fluid status, it is not the immediate priority. A neuro assessment is a more critical and immediate action to evaluate for signs of central nervous system dysfunction. *.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A reactive Non-Stress Test is a positive indicator of fetal health and a well-oxygenated central nervous system. This is defined by the occurrence of at least two fetal heart rate accelerations, each peaking at 15 beats per minute above the baseline and lasting for 15 seconds, within a 20-minute period. This response confirms a healthy, non-compromised fetus.
Choice B rationale
A non-reactive Non-Stress Test, not a reactive one, would indicate potential fetal distress or insufficient oxygenation. A reactive NST shows a healthy, active fetus with a heart rate that responds appropriately to its own movements, which is a sign of good fetal oxygenation and a healthy nervous system.
Choice C rationale
The criteria for a reactive NST in a fetus at 34 weeks or more is an acceleration of at least 15 beats per minute above the baseline, lasting for 15 seconds. The 10 beats per minute by 10 seconds criterion applies to fetuses less than 32 weeks, reflecting a less mature nervous system.
Choice D rationale
The Non-Stress Test (NST) is named such because it does not involve the use of uterine contractions to assess fetal response. This describes a Contraction Stress Test (CST) or an Oxytocin Challenge Test, which specifically evaluates the fetal heart rate response to uterine contractions to assess placental reserve. *.
Correct Answer is C
Explanation
Choice A rationale
While any serious maternal infection or complication can theoretically increase the risk of adverse pregnancy outcomes, including miscarriage, HSV infection is not a primary risk factor for spontaneous abortion. The greatest risk associated with HSV in pregnancy is the transmission of the virus to the neonate, particularly during vaginal birth. Miscarriage is more commonly linked to chromosomal abnormalities, uterine factors, or other maternal health conditions. The focus of care in HSV is preventing perinatal transmission.
Choice B rationale
Maternal pain and discomfort associated with a herpes simplex virus (HSV) outbreak are indeed a concern for the pregnant woman. The lesions can be painful and distressing. However, from a medical and fetal health perspective, this is not the greatest concern. The pain and discomfort are temporary and can be managed with supportive care. The potential for serious, life-threatening consequences for the newborn far outweighs the maternal symptoms.
Choice C rationale
The greatest concern regarding maternal herpes simplex virus (HSV) infection is the potential for transmission to the newborn during delivery, especially if the mother has an active primary genital outbreak. Neonatal herpes is a serious and potentially fatal condition that can lead to disseminated disease, central nervous system involvement, or skin, eye, and mouth disease. The risk is highest with a primary infection near term, as the mother has not yet developed protective antibodies to pass to the fetus. A cesarean section is often recommended if active lesions are present.
Choice D rationale
The development of oral cold sores, caused by HSV-1, is generally not the primary concern in the context of pregnancy. While oral HSV can be transmitted to a newborn, the risk is typically much lower and the consequences less severe than with genital HSV transmission during delivery. The focus of concern for maternal-fetal health is primarily on genital herpes outbreaks, particularly a primary infection at the time of delivery, due to the high risk of severe neonatal morbidity and mortality
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