NCLEX Practice Test

The nurse on the antepartum unit is performing shift assessments of several pregnant clients. Which client assessment is the priority to report to the health care provider?

1. Client with gestational diabetes mellitus reporting dysuria

2. Client with hyperemesis gravidarum with a blood pressure of 90/48 mm Hg

3. Client with oligohydramnios and a reactive fetal nonstress test

4. Client with preeclampsia with 3+ reflexes and 2 beats of clonus

The correct answer is: Client with gestational diabetes mellitus reporting dysuria

The priority assessment to report to the health care provider in this scenario is the client with hyperemesis gravidarum presenting with a blood pressure of 90/48 mm Hg. In the context of pregnancy complications, hyperemesis gravidarum is characterized by severe nausea and vomiting that can lead to dehydration and significant electrolyte imbalances. A blood pressure of 90/48 mm Hg indicates hypotension, which can suggest that the client may be facing a significant fluid deficit or other complications related to hyperemesis gravidarum. This hypotension could lead to serious concerns for maternal and fetal well-being, warranting immediate evaluation and possible intervention by the health care provider. The other assessments, while important, do not indicate an immediate threat that requires urgent reporting. The client with gestational diabetes reporting dysuria should certainly be assessed for a urinary tract infection, as this could have implications for both maternal and fetal health, but it is not as acute as hypotension from hyperemesis. The client with oligohydramnios and a reactive fetal nonstress test indicates that fetal well-being is stable, and while ongoing monitoring may be needed, it does not pose an immediate risk. Lastly, the client with preeclampsia showing 3