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
A history of cesarean section for fetal distress is an indication for a repeat cesarean section in subsequent pregnancies, as the risk of recurrence of fetal distress is higher. A trial of labor after cesarean (TOLAC) may be attempted in some cases, but a planned cesarean section is often recommended.
Option B is incorrect because fear of natural childbirth is not a medical indication for a cesarean section.
Option C is incorrect because gestational diabetes does not typically require a cesarean section unless other complications arise, such as fetal macrosomia or failed induction of labor.
Option D is incorrect because a history of cephalopelvic disproportion with the first pregnancy may not necessarily require a cesarean section in subsequent pregnancies. A trial of labor may be attempted, depending on the circumstances.
Correct Answer is A
Explanation
Assessing fetal heart rate (FHR) and maternal vital signs would be the highest priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy. This is because fetal distress or maternal instability may require immediate medical intervention, such as delivery via emergency cesarean section or blood transfusions, respectively.
Therefore, assessing the FHR and maternal vital signs will help to determine the urgency of the situation and guide the next steps in the management of the patient. Once the patient's condition has stabilized, performing venipuncture for hemoglobin and hematocrit levels, monitoring uterine contractions, and placing clean disposable pads to collect any drainage can be done as appropriate.
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