A 25-year-old primigravida is 8 months pregnant and is in the office for her regular prenatal checkup. She complains of occasional rather severe headaches. The nurse should first
a. check her urine for protein
b. instruct her to take Tylenol (acetaminophen) instead of aspirin for headache
c. report this finding immediately to the doctor or certified nurse midwife
d. take her blood pressure
D
The nurse should first take her blood pressure because severe headaches may indicate pregnancy-induced hypertension or pre-eclampsia. Although proteinuria is common in pre-eclampsia, monitoring the client's blood pressure is a higher priority than checking her urine for protein. Assessment, such as taking the blood pressure, should be performed before reporting the findings in order to determine if the headaches are the result of a pregnancy-induced complication, such as pregnancy-induced hypertension.
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