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
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.
Correct Answer is D
Explanation
This comment by the practical nurse (PN) is likely to be the most helpful to the client. By offering to sit with the client, the PN shows empathy, support, and a willingness to provide companionship. This approach acknowledges the client's feelings of isolation and offers a listening ear. It provides an opportunity for the client to express his emotions, thoughts, or concerns if he wishes to do so. The presence of a caring and compassionate individual can help alleviate some of the client's feelings of loneliness and may encourage him to open up and engage in conversation or activities when he is ready.
A. "Come into the recreation area. We have your favorite card game and I will play it with you."
This choice assumes that engaging in a specific activity will automatically help the client and solve his current feelings of reclusiveness. While offering an activity may be beneficial in some cases, it is important to first address the client's emotional state and provide support before suggesting specific activities. Pushing the client to participate in an activity without acknowledging his current feelings may further alienate him and not address the underlying issues causing his reclusive behavior.
B. "Why do you want to stay in your room today?"
This choice may come across as confrontational or judgmental. Asking why the client wants to stay in his room implies that there is something wrong with his decision or that he needs to justify his behavior. This approach may make the client defensive or withdraw further. It is essential to create a safe and supportive environment where the client feels understood and validated, rather than questioning his choices.
C. "I know you are sad about not seeing your family as often, but they are visiting as much as they can."
While acknowledging the client's sadness about not seeing his family is important, dismissing his feelings by stating that his family is visiting as much as they can minimize or invalidate his emotions. It is crucial to provide empathy and validate the client's emotions without making assumptions or downplaying his experiences. This approach may not address the client's current state of reclusiveness or provide the support he needs.
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