A nurse is caring for a client who is at 32 weeks of gestation and reports lower abdominal cramping.

Which of the following actions should the nurse take first?

Assess the client’s vital signs

Perform a sterile vaginal exam

Administer tocolytic medication

Monitor the fetal heart rate

Answer and Explanation

The Correct Answer is A

Assess the client’s vital signs.

The nurse should first assess the client’s vital signs to determine the severity of the situation and identify any signs of infection, bleeding, or shock.

The nurse should also monitor the fetal heart rate to assess fetal well-being.

Choice B is wrong because a sterile vaginal exam is not indicated for a client who reports lower abdominal cramping and may increase the risk of infection or rupture of membranes.

Choice C is wrong because administering tocolytic medication is not the first action the nurse should take.

Tocolytic medication may be used to inhibit uterine contractions and prolong pregnancy, but only after assessing the client’s and fetus’s condition and obtaining a prescription from the provider.

Choice D is wrong because monitoring the fetal heart rate is not the first action the nurse should take.

Monitoring the fetal heart rate is important to assess fetal well-being, but it does not take priority over assessing the client’s vital signs.

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Correct Answer is B

Explanation

Drinking enough water can help prevent dehydration, which can trigger preterm labor contractions.Dehydration can also cause low amniotic fluid levels, which can affect fetal growth and development.

Choice A is wrong because avoiding sexual intercourse until term is not necessary for most women at risk for preterm labor.Sexual activity does not cause preterm labor unless there are other complications, such as placenta previa or cervical insufficiency.

Choice C is wrong because lying down when feeling contractions may not stop preterm labor.If a woman has regular contractions that cause cervical change, she should seek medical attention as soon as possible.Lying down may also reduce blood flow to the uterus and placenta, which can affect fetal oxygenation.

Choice D is wrong because taking aspirin for pelvic pain is not recommended for pregnant women.Aspirin can increase the risk of bleeding and affect fetal blood circulation.

Pelvic pain may be a sign of preterm labor or other complications, so it should be evaluated by a health care provider

A. Administer a dose of tocolytic medication B. Encourage the client to rest in a side-lying position C. Assess fetal heart rate using a Doppler device D. Assess vaginal discharge for any change

Correct Answer is C

Explanation

Assess fetal heart rate using a Doppler device.

This is because low back pain and pelvic pressure at 36 weeks of gestation may indicate preterm labor, which can affect the fetal well-being.Therefore, the nurse should assess the fetal heart rate as a priority to determine if the fetus is in distress or not.

Choice A is wrong because tocolytic medication is used to stop uterine contractions, not to relieve low back pain and pelvic pressure.Choice B is wrong because resting in a side-lying position may help with blood circulation and reduce supine hypotensive syndrome, but it does not address the possible cause of low back pain and pelvic pressure.Choice D is wrong because assessing vaginal discharge for any change may indicate infection, rupture of membranes, or cervical dilation, but it is not as urgent as assessing fetal heart rate.

Some interventions for preventing and treating low back pain and pelvic pressure during pregnancy include exercise, water-based exercise, acupuncture, osteomanipulative therapy, craniosacral therapy, and pelvic support belts.

However, these interventions should be discussed with the health care provider before starting them.

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A nurse is caring for a client who is at 32 weeks of gestation and reports lower abdominal cramping. Which of the following actions should the nurse take first?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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A nurse is caring for a client who is at 32 weeks of gestation and reports lower abdominal cramping.

Which of the following actions should the nurse take first?