A client who is 32 weeks gestation comes to the women's health clinic and reports nausea and vomiting. On examination, the nurse notes that the client has an elevated blood pressure. Which action should the nurse implement next?
Inspect the client's face for edema
Ascertain the frequency of headaches
Evaluate for history of cluster headaches
Observe and time client's contractions
The Correct Answer is A
Inspect the client's face for edema:
Elevated blood pressure during pregnancy may be a sign of preeclampsia, a condition that can involve fluid retention. Edema, particularly in the face, is one of the signs that the nurse should assess for in determining if preeclampsia is a concern.
Ascertain the frequency of headaches:
Frequent headaches can be a symptom of various conditions, including preeclampsia. Gathering information about the frequency and characteristics of headaches can provide additional data for assessing the client's overall condition.
Evaluate for history of cluster headaches:
Cluster headaches, while severe, are not typically associated with elevated blood pressure during pregnancy. This information might not be directly relevant to the client's current symptoms.
Observe and time client's contractions:
Contractions are not typically associated with nausea, vomiting, or elevated blood pressure during pregnancy. This action may not address the primary concerns presented by the client.
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Related Questions
Correct Answer is C
Explanation
A. Notify the healthcare provider of the complaint: While it's important for the healthcare provider to be aware of any changes or symptoms the client is experiencing, the described discharge is commonly associated with normal physiological changes in pregnancy.
B. Recommend an over-the-counter yeast medication: The characteristics of the discharge described (white, thin, and watery) are not typical of a yeast infection. Using over-the-counter medications without proper assessment can lead to unnecessary treatment.
C. Inform her that this is a normal physiological change: This is the most appropriate action. Increased vaginal discharge, often described as leukorrhea, is a common and normal change during pregnancy. It's generally thin, white, and watery.
D. Prepare the client for a sterile speculum exam: A sterile speculum exam may be indicated if there are other concerning symptoms or if the discharge changes in color, consistency, or if there is associated itching or foul odor. However, based on the information provided, it's not the first-line action.
Correct Answer is C
Explanation
A. Avoid alcohol, caffeine, and smoking: This is generally good advice during pregnancy to promote a healthy environment for the developing fetus, but it may not specifically address nausea.
B. Eliminate between meal snacks: While this might be suggested for some individuals, keeping something light on the stomach, like crackers, can sometimes help alleviate nausea.
C. Practice relaxation techniques when the nausea first begins: Relaxation techniques, such as deep breathing or meditation, can be beneficial in managing nausea, especially if stress or anxiety contributes to the symptoms.
D. Increase intake of fluids to 3 quarts daily: Staying hydrated is important during pregnancy, but drinking too much fluid at once might not necessarily alleviate nausea and could potentially make it worse.
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