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 D

Explanation

All of the above.The nurse should include all of these signs and symptoms in the teaching as they may indicate pre-term labor.Pre-term labor occurs when regular contractions begin to open the cervix before 37 weeks of pregnancy.

Choice A is wrong because decreased fetal movement is not a normal sign of pre-term labor, but it may indicate fetal distress or other complications.

Choice B is wrong because increased vaginal discharge is not a normal sign of pre-term labor, but it may indicate infection or rupture of membranes.

Choice C is wrong because pelvic pressure is not a normal sign of pre-term labor, but it may indicate cervical dilation or descent of the fetus.

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.

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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

A nurse is teaching a client who is at risk for pre-term labor about the signs and symptoms to report to the provider. Which of the following should the nurse include in the teaching?

Correct Answer is D

Explanation

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Correct Answer is B

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?