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 ["0816"]
Explanation
To calculate the estimated date of delivery using Nägele's rule, follow these steps:
-Add 7 days to the first day of the last menstrual period. In this case, November 9 + 7 days = November 16.
- Subtract 3 months from the month of the last menstrual period. In this case, November - 3 months = August.
The estimated date of delivery is August 16
The rationale for this rule assumes that the average menstrual cycle is 28 days long and that ovulation occurs on day 14 of the cycle. Therefore, adding 7 days to the first day of the last menstrual period approximates the date of conception. Subtracting 3 months from the month of the last menstrual period adjusts for the difference between the lunar calendar (13 months) and the Gregorian calendar (12 months).
Correct Answer is D
Explanation
Choice A rationale:
Identifying whether incivility is present is important, but it's more proactive to initially focus on promoting a safe environment.
Choice B rationale:
Modeling professional behavior is essential, but addressing incivility requires a comprehensive approach that involves the entire team.
Choice C rationale:
Developing a zero-tolerance policy is important, but it should come after promoting a safe and respectful environment.
Choice D rationale:
Creating an emotionally safe environment fosters open communication and helps prevent incivility from occurring in the first place.
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