Practice Question
A nurse is providing care at a routine visit for a client who is at 36 weeks of gestation.
Answer Choices:
Correct Answer:
Cerebral manifestations
Rationale:
Cerebral manifestations
🔹 The client reports a headache persisting for several days that has now become more severe (5/10) and is accompanied by dizziness when standing.
🔹 These are neurologic (cerebral) signs that may indicate increasing central nervous system irritability, a hallmark feature of worsening preeclampsia.
🔹 Although the client denies visual disturbances, the worsening headache and dizziness still warrant immediate provider notification, as they may precede seizures (eclampsia).
🔹 Early detection of cerebral symptoms is critical in preventing serious maternal complications.
Blood pressure
🔸 The client has elevated BP readings: 156/90 mm Hg at 0900 and 160/96 mm Hg at 1000, both of which meet criteria for mild to severe hypertension in pregnancy.
🔸 Persistent blood pressure readings ≥140/90 mm Hg after 20 weeks of gestation suggest gestational hypertension or preeclampsia.
🔸 BP ≥160 systolic or ≥110 diastolic are thresholds for severe features and require prompt intervention.
🔸 Timely provider notification is essential to initiate lab work, fetal monitoring, or magnesium sulfate therapy if preeclampsia with severe features is confirmed.
Gastrointestinal assessment findings
🟢 The client reports “heartburn”, which may actually reflect epigastric pain—a classic symptom of liver involvement in severe preeclampsia or HELLP syndrome.
🟢 In pregnancy, true epigastric pain related to preeclampsia is due to hepatic swelling or irritation, and often mistaken for indigestion or reflux.
🟢 This symptom, especially when combined with headache and edema, should be taken seriously and immediately communicated to the provider for evaluation.
🟢 It may signal impending eclampsia or liver damage, which requires immediate lab work (LFTs, platelets) and potential hospital admission.
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This question is from Custom NIJR209 Final ASSESSMENT SP-2024 which contains 9 questions.
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A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with the Plastibell technique. Which of the following client statements indicates understanding of circumcision care? (Select all that apply.)
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN Custom Exam(s)
- Answer Choices: 6