A nurse inadvertently administers 160 mg of valsartan PO to a client who was scheduled to receive 80 mg.

Which of the following actions is the priority for the nurse to take?

The correct answer is choice D, spotting.

Placenta previa is a condition where the placenta implants in the lower part of the uterus, partly or completely covering the cervical opening.

This can cause painless, bright red vaginal bleeding, usually in the third trimester.

Spotting is a sign of placenta previa and should be reported to the provider immediately.

Choice A is wrong because nausea is not a specific finding of placenta previa.

Nausea can occur in normal pregnancy or in other conditions such as hyperemesis gravidarum or preeclampsia.

Choice B is wrong because polyhydramnios is not a finding of placenta previa.

Polyhydramnios is a condition where there is too much amniotic fluid in the uterus, which can cause complications such as preterm labor, cord prolapse, or fetal malformations.

Choice C is wrong because uterine tenderness is not a finding of placenta previa.

Uterine tenderness is a sign of abruptio placentae, which is a condition where the placenta separates from the uterine wall before delivery.

This can cause severe abdominal pain, dark red vaginal bleeding, and fetal distress.

The correct answer is D. Remind the client to use the incentive spirometer.

Choice A rationale:

Observing the position of the suspended weight is beyond the scope of practice for assistive personnel (AP). This task requires assessment skills to ensure proper alignment and functioning of the traction system, which is the responsibility of the nurse.

Choice B rationale:

Checking the client’s pedal pulse on the right leg involves assessment and clinical judgment to evaluate perfusion and detect potential complications such as impaired circulation. This is not a task that can be delegated to AP.

Choice C rationale:

Asking the client to describe her pain requires assessment and interpretation of subjective data, which falls under the nurse's scope of practice. Pain assessment is a critical nursing function.

Choice D rationale:

Reminding the client to use the incentive spirometer is a non-assessment task that involves reinforcing previously taught instructions. This is appropriate to delegate to assistive personnel, as it does not require clinical judgment.