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 C
Explanation
This tool helps in assessing the severity of withdrawal symptoms in infants who were exposed to opioids during pregnancy. Based on the Finnegan score, the nurse can implement appropriate interventions to manage the symptoms and prevent complications. While offering the infant a pacifier with a drop of mom's breast milk or tightly swaddling the infant may be helpful for soothing the infant, these interventions may not directly address the underlying hyperreflexia associated with opioid withdrawal. Placing the infant under a radiant warmer is not indicated for managing hyperreflexia.
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.
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