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

Answer and Explanation

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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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Insert a Foley catheter with a urimeter to monitor hourly output: This is a reasonable intervention because magnesium sulfate can affect renal function, and monitoring urinary output is essential. However, there's a more critical intervention to consider first.

B. Have calcium gluconate immediately available: This is the highest priority. Magnesium sulfate toxicity can lead to neuromuscular blockade, and calcium gluconate is the antidote. Having it readily available is crucial in case signs of magnesium toxicity (such as loss of deep tendon reflexes) appear.

C. Provide a quiet environment with subdued lighting: While maintaining a calm environment is generally important for clients on magnesium sulfate, it is not the highest priority in this situation.

D. Assess deep tendon reflexes (DTRs) every 4 hours: This is an important part of monitoring for magnesium sulfate toxicity. However, the immediate availability of calcium gluconate is the highest priority in case toxicity occurs.

A. Provide information about the high risk nature of her pregnancy B. Explain the benefits of a five-year post-transplant waiting period C. Gently remind the client that anti-rejection drugs cause sterility D. Determine if the client is considering options for adopting a child

Correct Answer is B

Explanation

A. Provide information about the high-risk nature of her pregnancy:

While it is true that pregnancies after organ transplantation are considered high-risk due to potential complications, the initial recommendation often involves waiting for a specified period.

B. Explain the benefits of a five-year post-transplant waiting period

After a liver transplant, healthcare providers typically recommend waiting for a certain period before attempting pregnancy. This waiting period allows the individual's health to stabilize, and it ensures that the transplanted organ is functioning optimally. Pregnancy, being a physiological stressor, can pose additional challenges to individuals with transplants. Waiting for a few years post-transplant is a precautionary measure to minimize potential risks.

C. Gently remind the client that anti-rejection drugs cause sterility:

This statement is not accurate. Anti-rejection drugs can affect fertility, but they do not cause sterility. The discussion should focus on the potential risks and safety considerations for pregnancy after a liver transplant.

D. Determine if the client is considering options for adopting a child:

While adoption might be an option, the primary intervention should involve discussing the waiting period and potential risks associated with pregnancy after a liver transplant.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer magnesium sulfate to a laboring client whose blood pressure has increased from 110/60 mmHg to 140/90 mmHg Which nursing protocol has the highest priority?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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