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. Monitor blood pressure, pulse, and respirations every 4 hours: Monitoring vital signs is important, especially in a client with eclampsia. However, the frequency of monitoring may need to be increased, particularly if the client's condition is unstable.
B. Keep an airway at the bedside: This is a crucial intervention. Eclampsia can lead to seizures, and having airway management equipment readily available is essential to ensure the client's safety during and after a seizure.
C. Allow liberal family visitation: While family support is important, the priority in eclampsia management is the safety and well-being of the client. Family visitation should be allowed, but it may need to be balanced with the need for a controlled and safe environment.
D. Assess temperature every hour: While monitoring temperature is a part of routine care, it may not be the highest priority in the context of eclampsia. Monitoring for signs of imminent seizure activity and maintaining a safe environment take precedence.
Correct Answer is C
Explanation
A. Instruct the client to maintain bed rest for 24 hours:
There is no clear indication for bed rest based solely on a slightly elevated temperature. Bed rest is not a standard recommendation for this situation.
B. Encourage the client to increase her intake of oral fluids:
Increasing fluid intake is a general recommendation for mild elevations in temperature. Adequate hydration can support the body's natural response to infection or inflammation.
C. Schedule a visit with the healthcare provider today:
This option is a prudent choice. A temperature elevation after a medical procedure may indicate an infection, and it's appropriate to schedule a visit with the healthcare provider for further evaluation.
D. Verify the administered Rho(D) immune globulin's compatibility:
While verifying the compatibility of the administered medication is important, it is not the primary concern when a client reports an elevated temperature. In this context, addressing the temperature and potential infection takes precedence.
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