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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Referral to community services for support.

Referral to community services for support is an important part of the discharge plan for a client in preterm labor.Community services can provide education, counseling, home visits, and other resources to help the client cope with preterm labor and prevent complications.

B. Encouragement to smoke in moderation.Statement is wrong because smoking is harmful for the unborn baby and can increase the risk of preterm labor.Smoking should be avoided completely during pregnancy and the client should be advised to quit or seek help to quit.

C. Instructions for heavy lifting and strenuous exercise.Statement is wrong because heavy lifting and strenuous exercise can trigger contractions and worsen preterm labor.The client should be instructed to rest as much as possible and avoid activities that may cause uterine irritation or bleeding.

D. Recommendation to avoid kangaroo care.Statement is wrong because kangaroo care, or skin-to-skin contact with the baby, is beneficial for both the mother and the baby after birth.Kangaroo care can help regulate the baby’s temperature, heart rate, breathing, and blood sugar levels, as well as promote bonding, breastfeeding, and infection prevention.The client should be encouraged to practice kangaroo care as soon as possible after delivery.

A. Hypotension B. Tachycardia C. Hyperglycemia D. Hypokalemia

Correct Answer is B

Explanation

Tachycardia.

Terbutaline is a medication that can be used to stop or delay preterm labor by relaxing the uterine muscles.However, it can also cause serious side effects for both the mother and the baby.One of the most common side effects of terbutaline is tachycardia, which means a fast or irregular heartbeat.This can lead to chest pain, palpitations, shortness of breath, and even cardiac arrhythmias or ischemia.

Therefore, the nurse should monitor the mother’s heart rate and rhythm closely when administering terbutaline.

Choice A is wrong because terbutaline does not cause hypotension, which means low blood pressure.In fact, terbutaline can increase blood pressure by constricting blood vessels.

Choice C is wrong because terbutaline does not cause hyperglycemia, which means high blood sugar.However, terbutaline can interfere with insulin secretion and glucose metabolism in some cases, especially in diabetic mothers.

Therefore, the nurse should monitor the mother’s blood sugar levels when administering terbutaline.

Choice D is wrong because terbutaline does not cause hypokalemia, which means low potassium levels in the blood.However, terbutaline can cause a temporary increase in potassium levels in the baby, which can affect the baby’s heart function.

Therefore, the nurse should monitor the baby’s heart rate and rhythm when administering terbutaline.

Normal ranges for heart rate are 60 to 100 beats per minute for adults and 120 to 160 beats per minute for fetuses.

Normal ranges for blood pressure aretypically between 90/60 mmHg and 120/80 mmHg.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client in pre-term labor is being discharged from the hospital. What should the nurse include in the client's discharge plan?

Correct Answer is A

Explanation

A nurse is administering terbutaline to a client who is at 31 weeks of gestation and has pre-term labor. Which of the following findings should the nurse monitor as an adverse effect of this medication?

Correct Answer is B

Explanation

A nurse is caring for a pregnant client at 36 weeks of gestation who reports low back pain and pelvic pressure. Which intervention should the nurse implement first?

A nurse is preparing to administer nifedipine to a client who is in pre-term labor. The nurse should withhold the medication and notify the provider if the client has which of the following conditions?

A client at 28 weeks of gestation presents with bleeding from the vagina. Which assessment finding should the nurse prioritize?

A nurse is educating a client who is at risk for pre-term labor about measures to prevent it from occurring. Which of the following instructions should the nurse include?

A nurse is evaluating the fetal heart rate tracing of a client who is in pre-term labor and receiving magnesium sulfate. The nurse should identify that which of the following patterns indicates a potential adverse effect of the medication on the fetus?

A nurse is evaluating a client who is at 28 weeks of gestation and has pre-term labor. Which of the following findings indicates that the client’s condition is improving?

A nurse is reviewing the laboratory results of a pre-term newborn who was born at 32 weeks of gestation. Which of the following values indicates a potential complication of necrotizing enterocolitis (NEC)?

A nurse is assessing a pre-term newborn who was born at 28 weeks of gestation. Which of the following findings indicates a possible diagnosis of respiratory distress syndrome (RDS)?

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?