Level: Foundational
Difficulty: Easy
Subtopic: Pregnancy complications
NCLEX: A 29-year-old client in labor and delivery is being evaluated for preeclampsia symptoms. Assessment data include…
Maternal-newborn nursing Health Promotion and Maintenance Reduction of Risk Potential
Case Study
A 29-year-old client in labor and delivery is being evaluated for preeclampsia symptoms. Assessment data include blood pressure 158/96 mm Hg with 3+ proteinuria and headache. Which nursing action is the priority to keep the client safe?
Question
A. Leave the client alone to promote independence while finishing charting.
B. Apply the first intervention in the policy manual without a current assessment.
C. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
D. Document the finding and recheck at the end of the shift without further assessment.
B. Apply the first intervention in the policy manual without a current assessment.
C. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
D. Document the finding and recheck at the end of the shift without further assessment.
Rationale
Correct answer: C. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
Rationale: Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.