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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Thromboembolism.
Prolonged bed rest increases the risk of venous stasis and blood clot formation in the lower extremities, which can lead to pulmonary embolism if the clot dislodges and travels to the lungs.
This is a life-threatening complication that requires immediate treatment.
Choice B. Placental abruption is wrong because it is not caused by bed rest, but by trauma, hypertension, cocaine use, or other factors that can cause the placenta to separate from the uterine wall.
Choice C. Uterine atony is wrong because it is not caused by bed rest, but by overdistension of the uterus, prolonged labor, infection, or other factors that can impair the contraction of the uterine muscles after delivery.
Choice D. Infection is wrong because it is not caused by bed rest, but by poor hygiene, invasive procedures, or other factors that can introduce microorganisms into the reproductive tract.
Normal ranges for maternal heart rate are 60-100 beats per minute and blood pressure are 110-140/60-90 mm Hg.
Normal range for fetal heart rate is 110-160 beats per minute.
Correct Answer is A
Explanation
Amniotic fluid index of 4 cm indicates oligohydramnios, which means too little amniotic fluid.This can cause fetal growth restriction, cord compression, and congenital anomalies.
Choice B is wrong because amniotic fluid index of 8 cm is within the normal range of 5 to 25 cm.
Choice C is wrong because amniotic fluid index of 12 cm is also within the normal range and close to the median value of 14 cm.
Choice D is wrong because amniotic fluid index of 16 cm is also within the normal range and does not indicate oligohydramnios.
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