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 A
Explanation
In the case of a prolapsed umbilical cord, the first priority intervention is to relieve pressure on the cord. Placing the woman in the knee-chest position or Trendelenburg position with the hips elevated is the best way to achieve this. This position helps to reduce the compression of the cord and improve fetal oxygenation.
Option B is incorrect because while oxygen may be necessary, relieving pressure on the cord is the priority.
Option C is incorrect because a vaginal birth should not proceed with a prolapsed umbilical cord, as it can cause cord compression and fetal distress.
Option D is incorrect because covering the cord in sterile gauze soaked in saline is not a priority intervention and may not be effective in relieving pressure on the cord.
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.
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