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 C
Explanation
Choice A rationale:
Sparse eyelashes are a common physical characteristic of individuals with Down syndrome and do not typically require immediate notification of the provider.
Choice B rationale:
Cracked skin on feet is not uncommon, and while it may need attention, it does not generally require immediate notification of the provider.
Choice C rationale:
Persistent neck pain in a child with Down syndrome could indicate an underlying issue and should be reported for further evaluation.
Choice D rationale:
Hyperflexibility is a common feature of Down syndrome and does not typically require immediate notification of the provider.
Correct Answer is B
Explanation
Choice A rationale:
Asking who the client talks to when overwhelmed is important, but assessing for suicidal thoughts is more urgent.
Choice B rationale:
Assessing the client's risk for harm to themselves is the priority when dealing with a person in crisis. This helps determine the need for immediate intervention to ensure their safety.
Choice C rationale:
Discussing the impact of the partner's death can be therapeutic, but ensuring immediate safety is the priority.
Choice D rationale:
Inquiring about coping strategies is important, but assessing for suicidal thoughts takes precedence.
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