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?

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The correct answer is choice c. Contractions.

Choice A rationale:

Epigastric pain is not a common complication following an amniocentesis. It is more often associated with conditions like preeclampsia or gastrointestinal issues.

Choice B rationale:

Hypertension is not directly related to amniocentesis. It is more commonly associated with conditions like preeclampsia or chronic hypertension in pregnancy.

Choice C rationale:

Contractions are a significant complication to monitor for after an amniocentesis, especially at 33 weeks of gestation. The procedure can sometimes induce preterm labor.

Choice D rationale:

Vomiting is not a typical complication following an amniocentesis. It may occur due to other unrelated reasons but is not directly linked to the procedure.

The correct answer is choice B. Applying an orthotic to the client’s foot.

An orthotic is a device that supports or corrects the function of a body part.

In this case, an orthotic can help prevent foot drop, which is a common contracture deformity in immobile patients.

Foot drop occurs when the muscles that lift the foot become weak or paralyzed, causing the foot to hang down at the ankle. An orthotic can keep the foot in a neutral position and prevent shortening of the calf muscles and Achilles tendon.

Choice A is wrong because a trochanter wedge is used to prevent external rotation of the hip, not contracture. A trochanter wedge is a triangular-shaped pillow that is placed between the legs to keep them parallel and aligned.

Choice C is wrong because a towel roll under the neck is used to maintain proper cervical alignment, not contracture. A towel roll can prevent hyperextension of the neck and support the natural curve of the spine.

Choice D is wrong because a pillow under the knees can actually cause contracture of the knee joint by keeping it in a flexed position. A pillow under the knees can also reduce blood flow to the lower extremities and increase the risk of deep vein thrombosis.

Contracture is a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen.

Contracture can limit the range of motion and function of the affected body part. Contracture can be caused by inactivity, scarring, or diseases that affect the muscles or nerves. Prevention of contractures requires early diagnosis and initiation of physical medicine approaches such as passive range of motion exercises and splinting before contractures are present or while contractures are mild.