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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Obtain a drug screen for cocaine: Given the symptoms described (tremulous, tachycardic, hypertensive), there may be concern about drug exposure, and cocaine is a substance known to cause such symptoms in newborns. Therefore, obtaining a drug screen for cocaine is a reasonable and important action to determine if there was prenatal exposure.
B. Weigh and measure the newborn: While weighing and measuring the newborn is a routine part of the newborn assessment, it may not be the most crucial action in this context. The symptoms described suggest the need for a more immediate assessment related to possible drug exposure.
C. Determine reactivity of neonatal reflexes: Assessing the reactivity of neonatal reflexes is an important part of the newborn assessment, but in this specific situation, the symptoms described (tremulous, tachycardic, hypertensive) may warrant a more focused and immediate assessment related to drug exposure.
D. Perform gestational age assessment: Gestational age assessment is essential for understanding the newborn's maturity and adjusting care accordingly. However, in this scenario, the immediate concern seems to be the symptoms the newborn is presenting with, and addressing the possibility of drug exposure takes precedence.
Correct Answer is C
Explanation
Level of pain sensation:
This is important for assessing the effectiveness of the epidural anesthesia, but it's not the most critical assessment immediately after administration.
Variability of fetal heart rate:
Monitoring fetal heart rate is always important, but immediately following epidural administration, the maternal blood pressure is a more immediate concern.
Maternal blood pressure:
This is the most critical assessment after epidural administration. Epidurals can cause a sudden drop in blood pressure, which may affect blood flow to the baby.
Station of presenting part:
The station of the presenting part (the position of the baby's head in relation to the ischial spines) is important for assessing progress in labor, but it's not the most crucial assessment immediately after epidural administration.
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