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A nurse working in labor and delivery is assisting in the care of a client who is at 30 weeks of gestation.

Exhibits

Select the 5 findings that the nurse should recommend for follow-up.

Persistent headache

Nausea and vomiting

Right epigastric pain

Slight facial edema

Heart rate of 88/min

Blood pressure of 140/90 mmHg

Proteinuria 2+

Deep tendon reflexes (DTR) 3+ bilaterally

Answer and Explanation

Correct Answer : A,B,C,G,H

The correct answer is choice A. Persistent headache, B. Nausea and vomiting, C. Right epigastric pain, G. Proteinuria 2+, H. Deep tendon reflexes (DTR) 3+ bilaterally. Choice A rationale: Persistent headache is a significant symptom that can indicate increased intracranial pressure or other serious conditions, especially in a pregnant client. It requires follow-up to rule out complications such as preeclampsia. Choice B rationale: Nausea and vomiting, particularly when severe and persistent, can lead to dehydration and electrolyte imbalances. In the context of pregnancy, it can also be a sign of a more serious underlying condition that needs to be addressed. Choice C rationale: Right epigastric pain is concerning as it can be indicative of liver involvement, which is a serious complication in pregnancy. This symptom needs immediate follow-up to assess for conditions such as HELLP syndrome. Choice D rationale: Slight facial edema can be a normal finding in pregnancy, but it can also be a sign of fluid retention associated with preeclampsia. However, on its own, it is not as critical as the other symptoms listed. Choice E rationale: A heart rate of 88/min is within the normal range for adults and does not typically require follow-up unless accompanied by other concerning symptoms. Choice F rationale: Blood pressure of 140/90 mmHg is elevated and concerning in pregnancy, but it is not included in the correct answers because the other symptoms are more directly indicative of severe complications. Choice G rationale: Proteinuria 2+ is a significant finding that suggests kidney involvement and is a key diagnostic criterion for preeclampsia. This requires immediate follow-up. Choice H rationale: Deep tendon reflexes (DTR) 3+ bilaterally are hyperactive and can indicate neurological irritability, which is a concerning sign in the context of preeclampsia. This finding needs follow-up to prevent complications such as seizures. Choice I rationale: Fundal height measurement of 26 cm at 30 weeks of gestation is below the expected range and may indicate intrauterine growth restriction (IUGR) or other issues, but it is not as immediately critical as the other findings listed.

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Correct Answer is C

Explanation

Choice A reason:

"You should administer the medication at bedtime." This statement is incorrect option. Administering methylphenidate at bedtime is not appropriate because it is a stimulant medication, and taking it in the evening could interfere with the child's ability to fall asleep and disrupt their sleep pattern.

Choice Breason:

"Your child should avoid foods containing tyramine. “This statement is incorrect option. Tyramine is not a concern with methylphenidate. Tyramine is associated with certain antidepressant medications, such as MAO inhibitors. Methylphenidate is not a MAO inhibitor, so there is no need for the child to avoid tyramine-containing foods.

Choice Creason:

"You should administer the medication after breakfast." This is the correct option. Administering methylphenidate after breakfast is a common practice because it allows the child to benefit from the medication during school hours when improved attention and focus are needed the most.

Choice Dreason:

"Your child should avoid excess sodium intake." This statement is an incorrect option. Excess sodium intake is not directly related to methylphenidate use. However, it is generally a good idea for anyone, including children, to have a balanced and healthy diet, which may include monitoring sodium intake. But it is not specifically tied to the administration of methylphenidate.

A. Administer diuretics. B. Place on bedrest C. Limit fluid intake. D. Apply support stockings.

Correct Answer is D

Explanation

Answer: D. Apply support stockings.

Rationale: Support stockings can help reduce ankle edema by promoting venous return and preventing fluid accumulation in the lower extremities. Diuretics, bedrest, and fluid restriction are not recommended for pregnant clients with ankle edema as they can cause dehydration, thromboembolism, and fetal compromise.

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A nurse working in labor and delivery is assisting in the care of a client who is at 30 weeks of gestation. Exhibits Select the 5 findings that the nurse should recommend for follow-up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a parent of a school-age child who is to begin a daily dose of methylphenidate. Which of the following should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is assisting with the plan of care for a client who is in the third trimester of pregnancy and has ankle edema. Which of the following interventions should the nurse include in the client's plan of care?

Correct Answer is D

Explanation

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A nurse working in labor and delivery is assisting in the care of a client who is at 30 weeks of gestation.

Exhibits

Select the 5 findings that the nurse should recommend for follow-up.