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    HESI RN HEALTH ASSESSMENT PROCTORED EXAM

    A client who is 32 weeks gestation arrives at the clinic reporting nausea and vomiting for the past 24 hours. The nurse reviews the record and observes there has been a rapid weight gain over six weeks. Which action should the nurse implement next?

    Explanation & Rationale

    A. Inspect for pedal edema. While pedal edema can be a sign of preeclampsia, obtaining blood pressure is a more immediate and crucial assessment.B. Obtain a blood pressure. This is the correct next step, as rapid weight gain and nausea/vomiting can be symptoms of preeclampsia, which is often accompanied by hypertension.C. Listen to foetal heart rate. This is important but secondary to assessing the mother's condition, especially when preeclampsia is suspected.D. Ask for a 24-hour diet recall. This might be relevant for nutritional assessment but is not the priority when preeclampsia is suspected.

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