A nurse is caring for a client who is at 36 weeks of gestation and reports a headache.
Which of the following actions should the nurse take? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)
Graphic Results Temperature 37° C (98.6° F) Heart rate 88/min Respiratory rate 18/min
Blood pressure 144/94 mm Hg
Upper abdominal pain rating 4/10 on a scale from 0 to 10
Perform a contraction stress test.
Prepare for delivery of the fetus.
Increase the client's dietary salt intake to 2 g/day.
Administer ferrous sulfate to the client.
Upper abdominal pain rating 4/10 on a scale from 0 to 10
The Correct Answer is B
Choice A rationale:
A contraction stress test is not appropriate in this context and would not address the potential risks associated with the client's symptoms.
Choice B rationale:
The elevated blood pressure and upper abdominal pain suggest potential preeclampsia, a serious complication of pregnancy that can lead to significant maternal and fetal risks. Delivery may be indicated to prevent further complications.
Choice C rationale:
Increasing dietary salt intake is not recommended for managing elevated blood pressure in pregnancy.
Choice D rationale:
Administering ferrous sulfate is unrelated to the client's symptoms and concerns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Placing objects within the client's reach on the right side helps to compensate for the hemiparesis and facilitates the client's ability to independently access items.
Choice B rationale:
Encouraging the client to repeat phonetic sounds might be more appropriate for speech therapy and may not directly address hemiparesis.
Choice C rationale:
Pausing to allow the client time to respond to questions is a communication technique but does not address the physical effects of hemiparesis.
Choice D rationale:
Frequently orienting the client to time, place, and surroundings is important for cognitive support but does not specifically address hemiparesis.
Correct Answer is C
Explanation
Choice A rationale:
Aphasia, or difficulty with language, is more commonly associated with left hemispheric stroke.
Choice B rationale:
Depression can be a common psychological reaction following stroke, but it is not a specific finding associated with right hemispheric stroke.
Choice C rationale:
Right hemispheric stroke can lead to loss of depth perception and spatial awareness due to its impact on the visual-spatial processing areas of the brain.
Choice D rationale:
Slow, cautious behavior is a common finding after stroke regardless of the affected hemisphere.
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