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 A
Explanation
A. Epinephrine relaxes the bronchioles and counteracts the effect of histamine: Epinephrine is the first-line treatment for anaphylaxis because it rapidly relaxes bronchial smooth muscles, reducing airway constriction, and counteracts histamine's effects, which include vasodilation, edema, and hypotension. This helps restore breathing and circulation.
B. Epinephrine should be given along with a beta blocker: Administering epinephrine with a beta blocker is dangerous because beta blockers can reduce the effectiveness of epinephrine and may worsen bronchospasm. Beta blockers are not recommended during acute management of anaphylaxis.
C. Epinephrine should be administered intranasally: Epinephrine is typically administered intramuscularly (IM), usually into the thigh, during anaphylactic emergencies for rapid absorption. Intranasal administration is not effective for treating life-threatening systemic allergic reactions.
D. Epinephrine causes a decrease in blood pressure: Epinephrine actually increases blood pressure by causing vasoconstriction. This counters the dangerous hypotension that occurs during anaphylaxis, helping to stabilize cardiovascular function quickly.
Correct Answer is D
Explanation
A. Apply a 9 kg (20 lb) weight to the traction: Buck’s traction is designed for short-term immobilization and uses lighter weights, typically between 2 to 5 kg (4.5 to 10 lb). Applying 9 kg (20 lb) would be excessive and could lead to nerve damage, impaired circulation, or additional injury.
B. Clean the pin insertion sites on a daily basis: Buck’s traction is a type of skin traction, not skeletal traction, and does not involve pins inserted into the bone. Therefore, there are no pin sites to clean in Buck’s traction, making this action irrelevant for the client’s care.
C. Remove the weights while the client is eating: Weights should never be removed or lifted unless there is a provider’s specific order to do so. Interrupting the continuous pull of the traction can cause misalignment of the fracture and delay healing.
D. Ensure that the weights are hanging freely: It is essential that the weights in Buck’s traction hang freely without resting on the floor or bed. This ensures a constant, steady pull on the extremity, which helps maintain proper alignment and promotes effective immobilization.
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