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 B
Explanation
The patient experienced a sudden guard while being assisted to the bathroom, which led to their hospitalization. The most appropriate action for the practical nurse (PN) in this situation is to prioritize the patient's safety and well-being. Returning the patient to bed and maintaining bed rest allows for stability and minimizes the risk of further complications or injury. By providing a safe and controlled environment, the PN can monitor the patient's condition and collaborate with the healthcare team to determine the appropriate course of action moving forward.
Options a), c), and d) are not relevant or appropriate in this context.
Correct Answer is A
Explanation
The practical nurse (PN) should observe minimal time, maximum distance, and protective shielding when administering direct care to a client who has four gold seed implants on a chest wall tumor.
Minimal time refers to limiting the duration of direct exposure to the client with the gold seed implants. This helps minimize the nurse's exposure to radiation.
Maximum distance refers to maintaining a safe distance from the client with the gold seed implants. The nurse should try to stay as far away as possible while still being able to provide necessary care.
Protective shielding involves using lead aprons, gloves, and other appropriate shielding materials to protect oneself from radiation exposure. These protective measures help reduce the nurse's exposure to radiation during care activities.
B. Rotating assignments with other staff during the shift may not be necessary in this situation unless there are specific staffing requirements or guidelines in place. The primary focus should be on minimizing the nurse's exposure to radiation through time, distance, and shielding.
C. Virtual observation and wearing a film badge for exposure are not applicable in this context. These measures are more relevant for monitoring radiation exposure over time and do not directly address the precautions needed during direct care.
D. Standard precautions with negative pressure isolation are not specifically indicated for a client with gold seed implants. Negative pressure isolation is typically used for clients with infectious diseases that require airborne precautions, and it is not directly related to radiation precautions.
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