A client with gestational hypertension reports abdominal pain and tenderness.
What should the nurse do first?
Administer acetaminophen
Assess blood pressure
Assess for visual disturbances
Assess for proteinuria
The Correct Answer is B
The correct answer is choice B. Assess blood pressure. The nurse should do this first because gestational hypertension is a condition that causes high blood pressure after 20 weeks of pregnancy and can lead to complications such as placental abruption or preeclampsia.
Abdominal pain and tenderness can be signs of these complications, so the nurse should check the blood pressure to determine the severity of the situation and plan further interventions.
Choice A is wrong because administering acetaminophen may not relieve the pain and may mask other symptoms.
Choice C is wrong because visual disturbances are not the most urgent symptom to assess in this case.
Choice D is wrong because assessing for proteinuria is not the first priority, although it is important to diagnose preeclampsia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. Assess blood pressure.This is because a severe headache can be a sign of elevated blood pressure, which can lead to preeclampsia and other complications in pregnancy.
Assessing blood pressure is the first step to determine the severity of the condition and the need for further interventions.
Choice A is wrong because administering acetaminophen may not address the underlying cause of the headache and may mask other symptoms.
Choice C is wrong because assessing for visual disturbances is not the first priority, although it can be a serious symptom of preeclampsia.
Blood pressure should be assessed first to determine the risk of eclampsia and other adverse outcomes.
Choice D is wrong because assessing for proteinuria is not the first priority, although it can be a diagnostic criterion for preeclampsia.
Blood pressure should be assessed first to determine the severity of the condition and the need for further interventions.
Correct Answer is A
Explanation
The correct answer is choice A. Administer oxygen.
The client is experiencing signs of pulmonary edema, which is a complication of gestational hypertension.
Oxygen therapy can help improve oxygenation and reduce the workload of the heart.
The nurse should also monitor the client’s vital signs, urine output, and magnesium sulfate level.
Choice B. Assess blood pressure.
This is an important action, but not the first priority.
The nurse should assess blood pressure after administering oxygen and stabilizing the client.
Choice C. Assess for visual disturbances.
This is a symptom of severe preeclampsia, but not an immediate threat to the client’s life.
The nurse should assess for visual disturbances as part of the ongoing evaluation of the client’s condition.
Choice D. Assess for proteinuria.
This is a diagnostic criterion for preeclampsia, but not a priority action in this situation.
The nurse should assess for proteinuria as part of the routine urinalysis.
Normal ranges for blood pressure are less than 140/90 mm Hg, and for proteinuria are less than 300 mg/24 hours.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.