How it Works
Try Naxlex NCLEX-RN (Free-Trial)

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

followed by

Answer and Explanation

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.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is C

Explanation

A. Place the client on bedrest: While limiting the client’s activity is important to reduce oxygen demand, it is not the first priority. Immediate actions should focus on improving oxygenation and reducing respiratory distress.

B. Obtain the client's ABG levels: Although obtaining arterial blood gases provides valuable information about oxygenation and acid-base balance, it does not address the immediate need to relieve the client's breathing difficulty and hypoxia.

C. Elevate the head of the client's bed: Elevating the head of the bed promotes lung expansion and improves oxygenation, making it the first action to reduce dyspnea and ease the client’s breathing. It is a simple, quick intervention that can stabilize the client while further assessments are conducted.

D. Prepare the client for a ventilation-perfusion scan: A V/Q scan may be indicated to diagnose conditions like pulmonary embolism, but it is a diagnostic step that follows stabilization. Immediate efforts must first focus on ensuring adequate oxygenation and respiratory support.

Correct Answer is A

Explanation

A. Take the medication with crackers: Taking doxycycline with food can help reduce gastrointestinal irritation, including nausea and vomiting. While it is not usually recommended to take doxycycline with food to ensure full absorption, in this case, eating crackers can help alleviate nausea and make the medication more tolerable.

B. Take the medication with an antacid: Antacids can interfere with the absorption of doxycycline, decreasing its effectiveness. Therefore, it is not recommended to take doxycycline with an antacid.

C. Take the medication and then lay down for 30 min: Lying down after taking doxycycline can increase the risk of esophageal irritation and ulceration. The medication should be taken while sitting or standing, and the client should remain upright for at least 30 minutes afterward.

D. Take the medication with calcium-fortified orange juice: Calcium can bind to doxycycline, decreasing its absorption and effectiveness. Therefore, it is not recommended to take doxycycline with calcium-fortified beverages.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register