A nurse is caring for a client during an initial prenatal visit.
The client's last menstrual period was 18 weeks ago.
Which of the following actions should the nurse plan to take?
Obtain the client's personal and family medical history.
Obtain information about prior pregnancies.
Check the client's urine with a reagent strip.
Schedule the client for prenatal laboratory testing.
Discuss chorionic villus sampling with the client.
The Correct Answer is A
Choice A rationale
Obtaining the client's personal and family medical history is essential during the initial prenatal visit. This history helps identify any genetic disorders or chronic conditions that might affect the pregnancy. It also provides insight into the client's overall health and any potential risk factors.
Choice B rationale
Information about prior pregnancies is important but not the first priority. Prior pregnancy information can provide insights into previous complications, but a comprehensive medical history should come first.
Choice C rationale
Checking the client's urine with a reagent strip is not the primary action during an initial visit. Urine tests are useful for detecting infections and certain conditions, but they come after a thorough history has been obtained.
Choice D rationale
Scheduling the client for prenatal laboratory testing is necessary, but it follows the initial assessment and history-taking. Laboratory tests help confirm the pregnancy and assess overall health but are not the first step.
Choice E rationale
Discussing chorionic villus sampling (CVS) is premature at this stage. CVS is a prenatal test conducted around 10-13 weeks for detecting chromosomal abnormalities, but it's not relevant during the initial visit without understanding the client's medical history.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale: Administer IV fluids with electrolytes: This is crucial to rehydrate the client and correct electrolyte imbalances caused by excessive vomiting, a common complication of hyperemesis gravidarum.
Choice B rationale: Offer small, frequent meals high in protein: Small, frequent meals can help manage nausea and vomiting by preventing the stomach from becoming empty, while high-protein foods can provide necessary nutrients and energy.
Choice C rationale: Administer antiemetics as prescribed: Antiemetics can help control nausea and vomiting, improving the client's ability to tolerate oral intake and maintain hydration and nutrition.
Choice D rationale: Encourage the client to increase oral fluid intake immediately: While increasing oral fluid intake is beneficial, it may not be immediately feasible due to the severity of nausea and vomiting in hyperemesis gravidarum. Hence, initial IV fluid therapy is prioritized.
Choice E rationale: Perform continuous fetal monitoring: Continuous fetal monitoring is not typically necessary in the early stages of pregnancy, especially at 11 weeks of gestation. The primary focus should be on stabilizing the mother's condition to support overall pregnancy health.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale
Rubella vaccination is contraindicated during pregnancy due to the risk of congenital rubella syndrome in the fetus. It should be administered postpartum if the client is non-immune.
Choice B rationale
Preterm labor is a concern at 28 weeks' gestation. Educating the client on signs and symptoms can help in early detection and management, potentially improving outcomes for both mother and baby.
Choice C rationale
Rh-negative mothers with a negative antibody screen should receive Rhogam at 28 weeks to prevent Rh sensitization. This is crucial to avoid hemolytic disease of the newborn in future pregnancies.
Choice D rationale
A positive urine analysis for leukocytes indicates a possible urinary tract infection. A clean catch urine culture is needed to identify the causative organism and guide appropriate antibiotic therapy.
Choice E rationale
The glucose challenge test result of 120 at 26 weeks is within normal limits, but a 3-hour diagnostic glucose tolerance test may be ordered if there's a high index of suspicion for gestational diabetes or other risk factors.
Choice F rationale
A blood transfusion is not indicated as the hemoglobin/hematocrit levels (11.0 mg/dl and 35%) are within acceptable limits for pregnancy.
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