During a routine prenatal visit at the antepartal clinic, a multipara at 35 weeks gestation presents with 2+ edema of the ankles and feet. Which additional information should the practical nurse (PN) report to the registered nurse?
Blood pressure.
Due date.
Fundal height.
Gravida and parity.
The Correct Answer is A
Edema, particularly if it is new or worsening, can be an indicator of preeclampsia, a potentially serious condition characterized by high blood pressure and organ dysfunction. Monitoring the client's blood pressure is crucial in assessing for signs of preeclampsia and determining the appropriate course of action.
B. Due date: The due date is an important piece of information for monitoring the progress of the pregnancy, but it is not directly relevant to the client's presenting symptom of edema. The focus should be on assessing for potential complications associated with edema, such as preeclampsia.
C. Fundal height: Fundal height is a measurement used to estimate fetal growth and position. While it is an important parameter to monitor during prenatal visits, it is not directly related to the client's edema. The priority in this situation is to assess for signs of preeclampsia or other complications, which may require assessing the blood pressure.
D. Gravida and parity: Gravida refers to the total number of pregnancies a woman has had, while parity refers to the number of pregnancies that have reached viability (20 weeks or more). While these pieces of information provide a background understanding of the client's obstetric history, they do not provide immediate insight into the current issue of edema. Assessing the blood pressure would be more relevant in this situation to identify any potential complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Are you planning to obey the voices?" – This question is crucial as it assesses the immediate risk of harm to the client or others. Determining if the client intends to follow commands from hallucinations provides insight into potential danger, ensuring safety is prioritized.
B. "Have you taken any hallucinogens?" – While drug use can contribute to hallucinations, asking about substance use is less urgent than assessing potential harm from the voices. Immediate safety takes precedence over exploring potential causes at this stage.
C. "When did these voices begin?" – Knowing when the symptoms started is relevant for understanding the history of the hallucinations but is secondary to determining if the client intends to act on any commands from the voices, as safety is the first priority.
D. "Do you believe the voices are real?" – This question helps assess the client’s insight into the hallucinations but is not as critical as assessing the immediate risk of harm by determining if the client plans to follow any commands from the voices.
Correct Answer is C
Explanation
The correct answer is C.
Choice A reason:
Repeating the heel stick for glucose in one hour is not the best first action because it delays necessary treatment and the infant's glucose could drop further, potentially causing harm.
Choice B reason:
Offering nipple feedings of 10% dextrose is not the initial treatment of choice for neonatal hypoglycemia. Oral dextrose gel may be used, but the priority is to provide a source of nutrition, such as breast milk or formula, which offers more sustained glucose levels.
Choice C reason:
Begin frequent feedings of breast milk or formula. This is the first intervention to implement because the infant's current glucose level is below the normal neonatal range of [30 to 60 mg/dL or 1.7 to 3.3 mmol/L], indicating hypoglycemia, which is common in infants of mothers with gestational diabetes. Immediate feeding can help raise the blood glucose level safely.
Choice D reason:
Assessing for signs of hypocalcemia is not the immediate priority. While hypocalcemia can occur in newborns, particularly those with maternal diabetes, the current symptoms and glucose level suggest hypoglycemia is the primary concern. Signs of hypocalcemia include irritability, muscle twitches, jitteriness, tremors, and poor feeding, which can overlap with hypoglycemia symptoms. However, the heel stick glucose level clearly indicates hypoglycemia, which should be addressed first.
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