A primigravida client who is at 33 weeks gestation presents to the labor and delivery unit troubled with a headache. The initial assessment findings include a blood pressure of 144/96 mm Hg, facial edema, and 3+ pitting edema in lower extremities. Which assessment should the nurse perform next?

Intensity of pain with contraction.

Fetal heart rate.

Temperature, pulse, and respirations.

Deep tendon reflexes and clonus.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Assessing pain intensity with contraction is not the priority when preeclampsia is suspected. The client's headache, hypertension, and edema indicate a need to evaluate for more specific signs of preeclampsia.

Choice B rationale

Fetal heart rate assessment is important, but evaluating maternal status is more urgent when preeclampsia symptoms are present. Monitoring maternal indicators helps determine the severity of preeclampsia.

Choice C rationale

Checking temperature, pulse, and respirations is part of routine assessment, but it does not provide specific information related to preeclampsia. Other assessments are more relevant for the client's condition.

Choice D rationale

Assessing deep tendon reflexes and clonus helps identify severe preeclampsia and potential for eclampsia. Hyperreflexia and clonus are signs of central nervous system irritability, requiring immediate attention and intervention.

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Correct Answer is A

Explanation

Choice A rationale

Postpartum preeclampsia symptoms include headache, nausea, dizziness, weakness, and visual disturbances due to increased blood pressure. Normal BP is <120/80 mmHg. Labs may show elevated liver enzymes and proteinuria.

Choice B rationale

Infections postpartum can cause fever, localized pain, and discharge but are less likely to present with headache, nausea, dizziness, and visual disturbances. Normal WBC is 4,000-11,000 cells/mcL.

Choice C rationale

Anemia due to blood loss may cause fatigue, dizziness, and weakness but usually doesn't present with headache and visual disturbances. Normal hemoglobin is 12-16 g/dL for women.

Choice D rationale

Normal postpartum fatigue generally doesn't include severe headache, nausea, dizziness, and visual disturbances. It is mainly characterized by tiredness and mild discomfort as the body recovers.

A. Check the differential, since the WBC is normal for this client. B. Assess the client’s perineal area for signs of a perineal hematoma. C. Assess the client’s temperature, heart rate, and respirations every 4 hours. D. Notify the healthcare provider (HCP), since this finding is indicative of infection.

Correct Answer is A

Explanation

Choice A rationale

The postpartum period is characterized by leukocytosis, where WBC counts can rise to 30,000/mm³ due to physiological stress. A WBC count of 15,000/mm³ is within the expected range for this client.

Choice B rationale

Perineal hematomas are more likely to cause localized pain and swelling than systemic symptoms. The assessment of perineal area is important but not the first priority in this context.

Choice C rationale

Monitoring temperature, heart rate, and respirations is crucial to identify infection but checking the differential to confirm normal physiological response to postpartum is prioritized first.

Choice D rationale

Notifying the HCP for an elevated WBC count without additional signs of infection is premature. A WBC count of 15,000/mm³ alone is not indicative of an infection in postpartum clients.

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A primigravida client who is at 33 weeks gestation presents to the labor and delivery unit troubled with a headache. The initial assessment findings include a blood pressure of 144/96 mm Hg, facial edema, and 3+ pitting edema in lower extremities. Which assessment should the nurse perform next?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

One day after vaginal delivery of a full-term baby, a postpartum client’s white blood cell (WBC) count is 15,000/mm³ (15 x 10⁹/L). Which action should the nurse take first?

Correct Answer is A

Explanation

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