A client who is 38 weeks pregnant is being monitored for pre-eclampsia.
She suddenly complains of continuous abdominal pain and vaginal bleeding.
Which of the following nursing interventions should not be included in the care of this client?

Reassure the patient that she will deliver vaginally.

Insert an indwelling Foley catheter.

Initiate IV therapy with Lactated Ringer's solution.

Monitor the fetal heart tracing.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Reassuring the patient that she will deliver vaginally is inappropriate and could be misleading, especially if there are complications such as placental abruption or severe pre-eclampsia, which may necessitate a cesarean delivery for the safety of the mother and baby.

Choice B rationale

Inserting an indwelling Foley catheter is a standard procedure to monitor urine output and kidney function, especially in cases of pre-eclampsia, where accurate monitoring of fluid balance is crucial.

Choice C rationale

Initiating IV therapy with Lactated Ringer's solution is important to maintain maternal hydration and electrolyte balance, especially if the client is experiencing blood loss and is at risk of hypovolemia.

Choice D rationale

Monitoring the fetal heart tracing is essential to assess the baby's well-being. Continuous fetal monitoring helps detect signs of fetal distress, allowing for timely interventions to ensure the safety of both mother and baby.

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Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"A"}}

Explanation

A. Pain: Consistent with both urinary tract infection (UTI) and preterm labor. UTI can cause dysuria and pelvic pain, while preterm labor can present with lower abdominal pain or cramping.

B. Vaginal discharge: Consistent with both urinary tract infection and preterm labor. UTI can cause unusual vaginal discharge due to infection, while increased or unusual discharge can be a sign of preterm labor.

C. Temperature: Consistent with urinary tract infection. Fever is a common symptom of UTI due to infection. Preterm labor usually does not involve a fever unless there is an infection present.

A. Gestational age. B. Vaginal examination. C. Uterine contractions. D. Birthing parent's blood pressure. E. Birthing parent's report of pain. F. Fetal heart rate.

Correct Answer is ["A","B","C","D"]

Explanation

Choice A rationale

Gestational age helps assess fetal development and potential complications. It is essential information for the provider to determine appropriate care and interventions.

Choice B rationale

Vaginal examination findings provide insight into cervical dilation, effacement, and station, which are critical for monitoring labor progress and making informed decisions about labor management.

Choice C rationale

Uterine contractions are a key indicator of labor progress. The frequency, duration, and intensity of contractions help the provider assess labor progression and plan necessary interventions.

Choice D rationale

Birthing parent's blood pressure is crucial for monitoring maternal well-being, especially in cases of pre-eclampsia or other hypertensive disorders. Elevated blood pressure can indicate complications that require immediate attention.

Choice E rationale

Birthing parent's report of pain, while important for comfort measures, is subjective and less critical for immediate clinical decision-making compared to the other findings.

Choice F rationale

Fetal heart rate monitoring provides essential information about the baby's well-being during labor. Abnormal heart rate patterns can indicate fetal distress and necessitate prompt intervention.

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A client who is 38 weeks pregnant is being monitored for pre-eclampsia.She suddenly complains of continuous abdominal pain and vaginal bleeding.Which of the following nursing interventions should not be included in the care of this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse reviews assessment findings. For each assessment finding, specify if the finding is consistent with a urinary tract infection or preterm labor. Each finding may support more than one disease process.

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"A"}}

Explanation

The nurse is contacting the provider regarding the client's status.Which of the following findings should the nurse report to the provider? Select the 4 findings the nurse should report:

Correct Answer is ["A","B","C","D"]

Explanation

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A client who is 38 weeks pregnant is being monitored for pre-eclampsia.
She suddenly complains of continuous abdominal pain and vaginal bleeding.
Which of the following nursing interventions should not be included in the care of this client?