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
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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Related Questions
Correct Answer is A
Explanation
Regular uterine contractions occurring every 15 minutes.
This finding suggests that the client may have placental abruption, which is a serious complication that requires immediate medical attention.Placental abruption is the premature separation of the placenta from the uterine wall, which can cause heavy bleeding, pain, and fetal distress.
Choice B is wrong because low back pain and pelvic pressure are common symptoms of preterm labor, which is not as urgent as placental abruption.
Choice C is wrong because a change in vaginal discharge is not a specific sign of any complication and may be normal in pregnancy.
Choice D is wrong because rupture of membranes is not a priority finding in this case, unless it is associated with infection or cord prolapse.
Correct Answer is B
Explanation
Cervix is shortened and thinned.This indicates cervical effacement, which is the thinning and softening of the cervix in preparation for childbirth.Cervical effacement is measured in percentages, from 0% (no effacement) to 100% (fully effaced).
Choice A is wrong because cervix is soft and pliable does not necessarily mean it is effaced.The cervix can soften before it thins and shortens.
Choice C is wrong because cervix is dilated and open indicates cervical dilation, which is the opening of the cervix.Cervical dilation is measured in centimeters, from 0 cm (closed) to 10 cm (fully dilated).
Cervical dilation and effacement are related, but not the same.
Choice D is wrong because cervix is posterior and high indicates the position of the cervix in relation to the vagina.The cervix can move from posterior (back) to anterior (front) and from high to low as labor progresses.
The position of the cervix does not indicate effacement.
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