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 A

Explanation

Encouraging the parents to touch and talk to the infant through the incubator ports can promote bonding between the infant and the parents.Bonding is the intense attachment that develops between parents and their baby, and it is essential for the baby’s social and cognitive development.Touch and communication are some of the ways that babies bond with their parents.

Choice B is wrong because limiting the parents’ visitation time can disrupt the bonding process and make the parents feel less involved in their baby’s care.

Choice C is wrong because eye contact is another way of bonding with babies, and it can help them feel secure and loved.

Choice D is wrong because holding and feeding the infant are also important ways of bonding, and they should not be restricted unless medically necessary.

A. Avoid sexual intercourse until term B. Drink at least 2 L of water per day C. Lie down when feeling contractions D. Take aspirin for pelvic pain

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

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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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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?