A client who is 32 weeks gestation arrives at the clinic reporting nausea and vomiting for the past 24 hours. The nurse reviews the record and observes there has been a rapid weight gain over six weeks. Which action should the nurse implement next?

Inspect for pedal edema.

Obtain a blood pressure.

Listen to fetal heart rate.

Ask for a 24-hour diet recall.

Answer and Explanation

The Correct Answer is B

A. Inspect for pedal edema. While pedal edema can be a sign of preeclampsia, obtaining blood pressure is a more immediate and crucial assessment.

B. Obtain a blood pressure. This is the correct next step, as rapid weight gain and nausea/vomiting can be symptoms of preeclampsia, which is often accompanied by hypertension.

C. Listen to foetal heart rate. This is important but secondary to assessing the mother's condition, especially when preeclampsia is suspected.

D. Ask for a 24-hour diet recall. This might be relevant for nutritional assessment but is not the priority when preeclampsia is suspected.

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Correct Answer is D

Explanation

A: Primary source of water. This assessment might be relevant if there is a concern about lead exposure or other contaminants in the water, which can contribute to anemia. Therefore, while important in certain contexts, it is not the most immediate assessment for these specific clinical manifestations.

B: Standard household income. Household income can influence access to nutritious food and overall health. Lower income can lead to food insecurity, poor diet quality, and subsequently, anemia and lower BMI due to inadequate nutrient intake. This can be an indirect but important factor to consider. However, it does not directly assess the child’s dietary intake or specific nutritional deficiencies.

C: Family history of eating disorders. Family history of eating disorders might provide insights into potential genetic or environmental predispositions to eating disorders. However, eating disorders are more commonly associated with adolescents and adults rather than school-age children.

D: Average daily intake of meals. This is the most directly relevant assessment. Analyzing the child's average daily intake of meals can provide immediate insights into potential nutritional deficiencies that might explain both the low hemoglobin level (anemia) and low BMI. Poor dietary intake, particularly of iron-rich foods, can lead to iron-deficiency anemia and inadequate caloric intake, affecting BMI. This assessment helps identify specific dietary issues that can be addressed directly to improve the child’s health.

A. Allow the client to compose herself then change the subject. B. "Why don't I come back in a few minutes after you are more composed." C. "I'm so sorry that I made you cry. I didn't mean to upset you." D. Offer a tissue and sit quietly until the crying subsides.

Correct Answer is D

Explanation

A. Allow the client to compose herself then change the subject.

This response allows the client some time to regain composure, which can be helpful. However, abruptly changing the subject may make the client feel dismissed or unheard. It's essential to address the emotional response with sensitivity.

B. "Why don't I come back in a few minutes after you are more composed."

While this response acknowledges the client's emotional state, it may unintentionally communicate a lack of availability or willingness to support the client in that moment. It's important for the nurse to offer support and empathy immediately rather than suggesting a delay.

C. "I'm so sorry that I made you cry. I didn't mean to upset you."

This response acknowledges the client's emotional response and expresses empathy, which is a crucial aspect of providing patient-centered care. However, it's important to avoid taking personal responsibility for the client's emotional reaction, as it may not have been caused solely by the nurse's questions.

D. Offer a tissue and sit quietly until the crying subsides.

This response demonstrates empathy and support by providing a tissue and offering a non-verbal gesture of comfort. Sitting quietly allows the client the space to express her emotions while feeling supported by the nurse's presence.

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A client who is 32 weeks gestation arrives at the clinic reporting nausea and vomiting for the past 24 hours. The nurse reviews the record and observes there has been a rapid weight gain over six weeks. Which action should the nurse implement next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A school-age child presents for a well-child visit with a hemoglobin level of 10 g/dL (100 g/L) and a body mass index of 15 kg/mm2. Which additional assessment should the nurse obtain to help identify a potential cause of these clinical manifestations?

Correct Answer is D

Explanation

A woman comes to the clinic for her first prenatal visit. The nurse is conducting a health history and the woman begins to cry when asked about previous pregnancies. Which response is best for the nurse to provide?

Correct Answer is D

Explanation

Gestational Ultrasound. In preparing the client for the procedure, the nurse should explain that the primary reason for conducting the ultrasound is to obtain which information?

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