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:
Poorly controlled blood sugar levels can lead to fetal overgrowth (macrosomia), which increases the risk of a large baby during delivery.
Choice B rationale:
High blood sugar levels after delivery are not specific to babies born to mothers with type 1 diabetes.
Choice C rationale:
Insulin dosage requirements often increase during the second and third trimesters due to insulin resistance, not decrease.
Choice D rationale:
The risk of ketoacidosis is not typically increased in the first trimester; rather, the focus is on controlling blood sugar levels to minimize risks to the developing fetus.
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.