A nurse is caring for a client who is pregnant.
Complete the following sentence by using the lists of options.
The provider has admitted the client to the inpatient obstetrics unit and written prescriptions based on the client's condition. The action the nurse should first assist with is
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D"}
- Reviewing fetal heart rate tracing: Reviewing the fetal heart rate tracing is the first action because the client has signs of severe preeclampsia, which can quickly lead to fetal distress. The fetal monitor will provide immediate information about the baby’s oxygenation status. Detecting any late decelerations or bradycardia would require urgent intervention to protect fetal life.
- Administering IM betamethasone: Administering IM betamethasone is important to accelerate fetal lung maturity in case early delivery is necessary. Since the client is only at 31 weeks, promoting lung development is crucial to improve neonatal outcomes. However, confirming fetal well-being comes first before giving medications.
- Scheduling an emergency cesarean section: An emergency cesarean section is not the first step without evidence of fetal compromise or maternal instability. At this point, the fetal heart rate shows moderate variability and accelerations, which are reassuring. A cesarean is only scheduled if fetal distress or worsening maternal condition occurs after further monitoring.
- Insert a Foley catheter to monitor urine output: Inserting a Foley catheter is important to monitor kidney function and fluid status in preeclampsia. Reduced urine output can signal worsening disease. However, it is not the priority over assessing the fetal condition first, because fetal distress can occur rapidly and needs immediate identification.
- Administering antibiotics: There is no current indication for administering antibiotics based on the client's data. The client does not have signs of infection, such as fever, elevated WBCs, or positive urinalysis for infection. Administering antibiotics would not address the current primary risks related to severe preeclampsia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "Your baby needs to suck on a pacifier.": While non-nutritive sucking on a pacifier can sometimes soothe a fussy baby, it is not the first recommendation, especially for a newborn who is establishing breastfeeding. Early introduction of pacifiers can interfere with successful breastfeeding due to nipple confusion.
B. "Breastfed babies are usually fussy from swallowing too much air during feedings.": Although some air swallowing can occur, especially if the latch is poor, this is not typically the primary reason for persistent crying. Addressing crying with soothing techniques like swaddling is a more immediate and supportive intervention for the parent.
C. "Swaddling your baby snugly in a blanket might help soothe her.": Swaddling provides warmth, security, and a sense of being back in the womb, which can calm a newborn effectively. It reduces the startle reflex and helps regulate the baby's nervous system, often resulting in decreased crying and improved comfort.
D. "Breastfed babies often need to be supplemented with formula.": Routine supplementation with formula is not recommended for healthy breastfed newborns unless there are clear medical indications. Promoting exclusive breastfeeding supports optimal nutrition, bonding, and gut health in the early postpartum period.
Correct Answer is B
Explanation
A. "A client must sign an Against Medical Advice form if he withdraws consent.": An Against Medical Advice (AMA) form is specifically used when a client chooses to leave a healthcare facility against medical advice, not when they withdraw consent for a procedure. Withdrawing consent does not require an AMA form and follows a separate legal and ethical process.
B. "A client can withdraw consent at any time after signing the informed consent form.": Clients maintain the right to autonomy throughout their care, including the right to withdraw consent at any point before or during a procedure. Signing the form does not waive their right to change their mind, and healthcare providers must respect this decision without penalizing the client.
C. "A client who is involuntarily admitted to a mental health unit cannot withdraw consent for treatment.": Even clients who are involuntarily admitted retain certain rights, including the right to refuse specific treatments unless they are legally deemed incompetent or pose an imminent threat. Involuntary admission does not mean automatic consent to all treatments.
D. "A client must provide a written refusal for a procedure for which he has already signed an informed consent.": Clients can verbally withdraw consent at any time; a written refusal is not legally required. While documentation of the client's decision is necessary for the medical record, insisting on a written refusal is not a legal prerequisite for withdrawal of consent.
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