QUESTION: "After instructing a pregnant client about third trimester edema, the nurse determines that the client needs further instruction when the client states which of the following?"
CHOICES
( X ) a.) "Swelling of my feet and ankles is normal."
( X ) b.) "I'll continue to drink six to eight glasses of water a day."
( X ) c.) "I need to avoid standing in one place for too long."
( O ) d.) "Swelling in my hands and face is to be expected."
RATIONALE: Although swelling of the feet and ankles is a common discomfort of pregnancy, such swelling, particularly during the last trimester, may be indicative of pregnancy-induced hypertension. If the client experiences swelling in the face or hands or has any visual disturbances, she needs to report these promptly. Swelling of the feet and ankles is a common discomfort of pregnancy. The client should continue to drink six to eight glasses of a noncaffeinated beverage or water daily to prevent dehydration. The client should elevate her feet whenever possible and avoid prolonged standing or sitting to promote adequate venous return. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
