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 readiness for induction of labor is assessed by determining the Bishop score. The Bishop score is a system used to evaluate the cervix for induction of labor readiness. It is based on the assessment of five factors: cervical dilation, cervical effacement, cervical consistency, cervical position, and fetal station. Each factor is scored on a scale of 0 to 3, with a maximum possible score of 15.
The higher the Bishop score, the more favorable the cervix is for induction of labor, and the higher the likelihood of a successful vaginal delivery. A Bishop score of 8 or higher is considered favorable for induction of labor. A low Bishop score may indicate that the cervix is not yet ripe and may need further cervical ripening before induction can be attempted.
The Apgar score is a test used to evaluate a newborn's physical condition at birth, based on five factors: appearance, pulse, grimace, activity, and respiration.
The biophysical profile is a prenatal ultrasound evaluation that assesses fetal well-being by evaluating fetal breathing, fetal movement, fetal tone, amniotic fluid volume, and fetal heart rate. Fetal position is an important consideration during labor, as it can impact the progression and outcome of labor, but it is not used to assess readiness for induction of labor.
Correct Answer is D
Explanation
Surveillance is the ongoing and systematic collection, analysis, and interpretation of health data for the purpose of monitoring health problems and trends. The Department of Health collects data on reportable diseases, including hepatitis B, to monitor disease incidence and inform public health interventions.
Descriptive epidemiology involves the study of the distribution and determinants of
health-related states or events in populations, while the epidemiological triangle is a model that describes the relationships among the agent, host, and environment in the development of disease.
Incident reporting refers to the documentation of adverse events or errors in healthcare settings.
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