The nurse is reviewing a woman's health care record during her first prenatal visit. The client has a history of chicken pox as a child and syphills as a teenager. Which action is most important for the nurse to take?
Obtain blood and urine for prenatal screens
Explain common complications of pregnancy
Obtain baseline blood pressure and weight
Schedule prenatal visits to occur monthly
The Correct Answer is A
A. Obtain blood and urine for prenatal screens.
This choice is important because it allows the nurse to assess the client's overall health, screen for infections, and identify any potential risks or complications that may impact the pregnancy.
B. Explain common complications of pregnancy.
While educating the client about common complications is valuable, it may not address the immediate need to screen for specific infections or assess the client's current health status. This information can be covered during prenatal education sessions.
C. Obtain baseline blood pressure and weight.
This is a routine part of prenatal care and is important for monitoring the client's health throughout pregnancy. However, if the client has a history of syphilis, obtaining specific prenatal screens (including for syphilis) would be a more targeted and immediate action.
D. Schedule prenatal visits to occur monthly.
Scheduling regular prenatal visits is essential for monitoring the progression of the pregnancy. However, addressing the specific health concerns and obtaining necessary screens take precedence during the initial visit, especially considering the client's history of syphilis.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Sleep deprivation:
While sleep is important for overall well-being, it may not be the top priority in this case. Fluid volume excess, given the client's cardiac history, poses a more immediate threat to health.
B. Fluid volume excess:
Clients with heart damage are prone to heart failure, and managing fluid balance is crucial. Excess fluid can worsen cardiac function, making this the priority concern.
C. Nausea and vomiting:
While nausea and vomiting are significant concerns, they might not be as directly related to the client's cardiac history as fluid volume excess. However, if severe, it could contribute to fluid imbalance.
D. Risk for infection:
Infection is a concern for postpartum clients, but in this case, the client's history of rheumatic fever and heart damage takes precedence. The priority is to prevent complications related to heart failure.
Correct Answer is A
Explanation
A. Use a fingertip to palpate the inguinal canal for a weakening or indentation:
This is a reasonable next step in assessing for undescended testes. Palpating the inguinal canal can help determine if the testes are located in the inguinal area.
B.Measure the size of the scrotal sac for length and width:
While scrotal size can be relevant in some contexts, it may not provide direct information about the presence or absence of the testes. Palpation or other methods are more specific for this purpose.
C. Perform transillumination of the scrotal sac to visualize shadows of the testes:
Transillumination involves shining light through tissues to detect structures. However, in the case of evaluating the presence of testes, palpation is usually a more direct and accurate method.
D. Observe the urethral opening on the surface of the penis when the newborn voids:
This option is unrelated to assessing the presence of testes. Observing the urethral opening is more relevant for assessing the anatomy of the penis.
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