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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Comfrey is not commonly recommended as an herbal supplement for menopausal symptoms. It has been associated with potential liver toxicity.
Choice B rationale:
Ginkgo biloba is often used to improve cognitive function and circulation but is not typically used to address menopausal symptoms.
Choice C rationale:
Black cohosh is an herbal supplement that is commonly used by middle-aged women to help alleviate symptoms related to menopause, such as hot flashes and mood swings. Black cohosh may also have some benefits for bone health and cardiovascular health. However, black cohosh may also have some side effects and interactions with other medications, so the nurse should advise the women to consult their health care providers before taking it.
Choice D rationale:
Garlic is not typically used as an herbal supplement to manage menopausal symptoms; it is more commonly known for its potential cardiovascular benefits.
Correct Answer is B
Explanation
Choice A rationale:
Understanding the relationship between food intake and the menstrual cycle is a relevant topic for individuals with anorexia nervosa.
Choice B rationale:
Rapid weight gain of 2 pounds per week can be concerning and may indicate an unhealthy pattern or behaviors related to the eating disorder.
Choice C rationale:
Recognizing that the body will never be perfect is a positive and realistic perspective that can contribute to a healthier mindset in individuals with anorexia nervosa.
Choice D rationale:
Taking a laxative for constipation is not uncommon among individuals with eating disorders, but the statement doesn't necessarily raise immediate concern compared to the rapid weight gain mentioned in choice B.
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