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
Bedrest is no longer recommended as it does not improve outcomes and may increase the risk of complications such as thromboembolism and pneumonia. Instead, patients with a placenta previa should be advised to avoid activities that may increase pelvic pressure, such as sexual intercourse, heavy lifting, and strenuous exercise. The other options are appropriate instructions to include in the patient's discharge plan.
Correct Answer is C
Explanation
Infants of diabetic mothers (IDM) are at risk of hypoglycemia because they have been exposed to high levels of glucose in utero. The fetus responds to this high glucose level by producing high levels of insulin to regulate the glucose level. After delivery, the glucose supply from the mother is cut off and the infant's insulin levels remain high, leading to hypoglycemia.
Additionally, the infant's ability to produce glucose is immature and may not be sufficient to maintain normal blood glucose levels, especially if the infant is premature or small for gestational age. Therefore, IDM requires close monitoring of their blood glucose levels to prevent and treat hypoglycemia.
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