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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Free Nursing Study Resources

Correct Answer is ["A","B","D"]

Explanation

"Use sunglasses if your eyes are sensitive to light.": After thyroid surgery, especially if the client has Graves’ disease and associated exophthalmos, the eyes may remain sensitive to light. Wearing sunglasses helps protect the eyes from irritation and prevents further discomfort while healing progresses.
"Continue eating foods with protein.": Maintaining adequate protein intake is important for healing after surgery. Protein supports tissue repair, immune function, and recovery, making it an essential part of the client’s postoperative nutrition plan.
"Remain on bedrest for 3 to 5 days following discharge.": Prolonged bedrest after thyroid surgery is not recommended. Early ambulation helps prevent complications such as blood clots and promotes recovery. Clients are usually encouraged to resume light activities shortly after surgery.
"You need to support your neck when coughing or moving.": After thyroidectomy, supporting the neck when coughing, sneezing, or repositioning helps protect the surgical site, reduces strain on the incision, and minimizes discomfort, promoting safer healing.
"You will no longer need to take any medications for your thyroid now that you have had surgery.": This is incorrect because many clients require lifelong thyroid hormone replacement therapy after a thyroidectomy to maintain normal metabolic function, depending on how much thyroid tissue was removed.

A. Limit periods of sitting in a chair to 4 hr. B. Avoid the use of draw sheets for repositioning C. Use a no-rinse perineal cleanser after incontinence. D. Keep the head of the client's bed elevated to 45.

Correct Answer is C

Explanation

A. Limit periods of sitting in a chair to 4 hr: Clients with urinary incontinence should avoid prolonged sitting because it increases pressure on the skin and raises the risk of skin breakdown. Sitting should be limited to shorter periods with frequent repositioning to protect skin integrity.

B. Avoid the use of draw sheets for repositioning: Draw sheets are helpful for repositioning clients safely and reducing friction and shear forces on the skin. Avoiding their use would increase the risk of skin injury, especially in clients with incontinence who are already vulnerable.

C. Use a no-rinse perineal cleanser after incontinence: Using a no-rinse perineal cleanser helps maintain skin hygiene, removes urine and feces gently, and prevents irritation or breakdown. It is an important part of incontinence care to protect the client's skin health.

D. Keep the head of the client's bed elevated to 45º: Elevating the head of the bed to 45º degrees is helpful for respiratory support but does not directly address urinary incontinence. Bed positioning should be adjusted based on overall client needs, not specifically to manage incontinence.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse has reviewed the Vital Signs at 1000. Which of the following statements should the nurse include when reinforcing teaching to the client following the procedure? Select all that apply.

Correct Answer is ["A","B","D"]

Explanation

A nurse is contributing to the plan of care for a client who has urinary incontinence. Which of the following interventions should the nurse include in the plan?

Correct Answer is C

Explanation

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A nurse is making client assignments for the next shift. The nurse should assign which of the following clients to the assistive personnel?

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