Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
33. A client, who is gravida 1, para 0 at 38 weeks' gestation, is found to have a blood pressure of 170/90 mm Hg. Which action should a nurse take first?
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
33. A client, who is gravida 1, para 0 at 38 weeks' gestation, is found to have a blood pressure of 170/90 mm Hg. Which action should a nurse take first?
. Evaluate the urine protein.
. Administer an analgesic.
. Assess fetal heart tones.
. Obtain a diet history.
Test-Taking Tip
Choose the option that will not delay the evaluation of whether or not this client has preeclampsia. The question only states the client has a single high blood pressure, which does not mean that the client has preeclampsia.
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
.
Answer 1 is correct because a high blood pressure (170/90 mm Hg) may be indicative of preeclampsia, or may be due to gestational hypertension, pain, or severe anxiety. The nurse needs to determine if the client has proteinuria. If there is proteinuria, the high blood pressure is suggestive of preeclampsia. Answer 2 is incorrect because administering an analgesic will not help to determine the cause of the high blood pressure in this client, and may delay the treatment if the client has preeclampsia. Answer 3 is incorrect because assessing fetal heart tones is a general assessment for all clients in the prenatal clinic; it is not a specific evaluation for the client's high blood pressure. Answer 4 is incorrect because obtaining a diet history is not the first action to take for this client. A diet history is appropriate for a client with hyperemesis, not possible preeclampsia.