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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.


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Related Questions

Correct Answer is D

Explanation

A. Perfectionistic: Perfectionism is more characteristic of obsessive-compulsive personality disorder, where individuals are overly focused on order, control, and achieving flawless standards. Clients with dependent personality disorder are more focused on relying on others for decision-making rather than striving for perfection.

B. Reclusive: Being reclusive, or socially withdrawn, is a common feature of avoidant personality disorder, not dependent personality disorder. Clients with dependent personality disorder typically seek out and maintain close relationships because they have an intense fear of being alone and unable to care for themselves.

C. Impulsive: Impulsivity is commonly associated with borderline personality disorder, where individuals act without considering consequences. Clients with dependent personality disorder tend to be cautious and overly reliant on others for guidance and approval, rather than acting impulsively on their own.

D. Submissive: Submissiveness is a hallmark of dependent personality disorder. Clients demonstrate extreme dependency on others for emotional and decision-making support, often avoiding disagreement and putting others' needs above their own to maintain relationships and avoid abandonment.

Correct Answer is D

Explanation

A. Gloves: Gloves are important for contact precautions but are not sufficient protection against airborne infections like tuberculosis. Tuberculosis spreads through respiratory droplets that remain suspended in the air, requiring specialized respiratory protection.

B. Gown: A gown is generally used when there is a risk of direct contact with infectious material. While gowns are important for many isolation precautions, they do not protect against airborne transmission of tuberculosis.

C. Dosimeter badge: A dosimeter badge measures exposure to radiation, not infectious agents. It is used in environments with radiologic procedures and is unrelated to protecting against infectious diseases like tuberculosis.

D. N95 respirator: An N95 respirator is specifically designed to filter airborne particles, including Mycobacterium tuberculosis. It fits tightly around the face and provides the necessary protection against inhaling infectious airborne pathogens in the client’s environment.

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