The home health nurse is assessing a 17-year-old pregnant client at 34 weeks of gestation who has been diagnosed with preeclampsia. Upon assessment, the nurse finds that the client has gained 2 pounds in the past week and her blood pressure is 144/92 mmHg. Which assessment finding would require further action by the nurse?
Visual disturbances
Frequent voiding in large amounts
1+ pedal edema
One headache in the past week
The Correct Answer is A
Visual disturbances would require further action by the nurse as they can be a sign of worsening preeclampsia and a potential indication for immediate medical attention. The client's recent weight gain and elevated blood pressure are also concerning findings, but visual disturbances are a more urgent symptom. Frequent voiding in large amounts and 1+ pedal edema are common in pregnancy, while one headache in the past week may or may not be significant depending on the context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Perineal hematoma is a complication that can occur after vaginal births, typically due to trauma or injury to the perineum during delivery. Wound dehiscence, UTIs, and DVTs are all possible complications associated with cesarean births. Wound dehiscence is a separation of the layers of the surgical incision, UTIs can occur due to catheterization during the surgery, and DVTs can occur due to immobility during the recovery period.
Correct Answer is B
Explanation
The patient should not be ambulating before the procedure as this may cause fetal descent and prevent the success of the version. The other interventions listed are appropriate and important for the safety and well-being of the patient and the fetus during the procedure.
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