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 B
Explanation
The Web of Causation model would be best for studying the complex relationships among factors that contribute to chronic disease. This model recognizes that chronic diseases result from the interplay of multiple factors at different levels, including individual, environmental, and societal factors. The model illustrates the complexity of these relationships and can help identify potential points for intervention.
Correct Answer is D
Explanation
The biophysical profile (BPP) would yield more detailed information about the fetus in this scenario. The BPP is a prenatal ultrasound evaluation that assesses fetal well-being by evaluating five biophysical variables: fetal breathing movements, fetal movements, fetal tone, amniotic fluid volume, and fetal heart rate. The BPP is a more detailed assessment of fetal well-being compared to a nonstress test and can provide valuable information about the fetus's overall health and well-being, including any potential issues or difficulties.
MSAFP screening is a blood test that can detect certain fetal abnormalities, but it does not provide detailed information about fetal well-being.
Percutaneous umbilical blood sampling (PLBS) is an invasive test that is used to obtain a sample of fetal blood for testing in cases of suspected fetal anemia or other blood disorders. Ultrasound for fetal anomalies is a diagnostic tool used to detect structural abnormalities or defects in the fetus. While it can provide some information about fetal well-being, it is not as comprehensive as the BPP in evaluating fetal health and wellness.
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