A client at 42-weeks gestation arrives at the labor and delivery unit for a scheduled induction but refuses the prescribed oxytocin infusion because she wants to have a "natural" delivery.

Which action is most important for the nurse to implement?

Choice A rationale:

Review the client's serum calcium level. Rationale: Checking the client's serum calcium level is not the most appropriate action in this situation. Hand and finger spasms during blood pressure measurement are more likely due to discomfort or muscle tension than a calcium deficiency. There is no immediate indication that the client's calcium level needs to be assessed urgently.

Choice B rationale:

Administer an as-needed (PRN) antianxiety medication. Rationale: Administering an antianxiety medication is not indicated in this situation. The client's symptoms of hand and finger spasms during blood pressure measurement are not likely related to anxiety. It is essential to address the immediate issue of obtaining an accurate blood pressure reading.

Choice C rationale:

Ask the UAP to take the blood pressure in the other arm. Rationale: This is the correct answer. When the UAP reports spasms in the client's right hand and fingers while taking blood pressure using the same arm, the nurse should prioritize obtaining an accurate blood pressure measurement. Asking the UAP to use the other arm can help ensure a more reliable reading. Muscle spasms in the arm being used for blood pressure measurement can lead to inaccurate results.

Choice D rationale:

Tell the UAP to use a different sphygmomanometer. Rationale: In this scenario, the issue appears to be related to muscle spasms in the client's hand and fingers rather than the sphygmomanometer itself. Changing the sphygmomanometer is unlikely to resolve the problem. The priority is to obtain an accurate blood pressure reading by addressing the spasms in the arm being used.

Choice A rationale:

Checking the client's temperature is important for assessing the client's condition, but it is not a priority before administering penicillin G IV for meningitis.

Choice B rationale:

Assessing the client's level of consciousness is essential for monitoring neurological status, but it is not the highest priority action before administering penicillin G IV for meningitis.

Choice C rationale:

Asking the client about any history of allergies is important for assessing potential allergic reactions to medications. However, the most critical action before administering penicillin G IV for meningitis is to obtain a blood sample for culture and sensitivity. This action helps identify the causative organism and guides appropriate antibiotic therapy, as meningitis can be life-threatening and requires prompt treatment.

Choice D rationale:

Obtaining a blood sample for culture and sensitivity is the highest priority action before administering penicillin G IV for meningitis. Identifying the specific pathogen responsible for the infection is crucial for selecting the most effective antibiotic therapy and preventing complications.