A nurse is caring for a client who is pregnant.
Complete the following sentence using the list of options.
The provider has admitted the client to an inpatient obstetrics unit and written prescriptions based on the client’s condition. The first action the nurse should take is
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
The first action the nurse should take is evaluating the fetal heart rate tracing, followed by administering labetalol IV.
Rationale for Correct Answers:
Evaluating the fetal heart rate tracing first is the priority because the client is at 31 weeks of gestation with severe preeclampsia and reported decreased fetal movement. Fetal assessment is time-sensitive; identifying any signs of fetal distress is critical to prevent hypoxia or other complications.
Administering labetalol IV is the next priority to manage the client’s severe hypertension (BP 166/110 mm Hg), which places both mother and fetus at risk for complications such as stroke, placental abruption, or fetal compromise.
Rationale for Incorrect options:
Administering acetaminophen PO addresses maternal headache but does not prevent immediate maternal or fetal complications, so it is lower priority.
Obtaining a 24-hour urine collection, betamethasone, and lactated Ringer’s are important interventions but are secondary to assessing fetal status and stabilizing maternal blood pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D"]
Explanation
A. Flossing is not typically required for toddlers until teeth touch each other closely (around 3 years old).
B. A toothbrush with soft nylon bristles is recommended for toddlers to clean teeth effectively without damaging gums.
C. Drinking milk at bedtime exposes teeth to sugars overnight, increasing the risk for dental caries (early childhood caries or “baby bottle tooth decay”).
D. A pea-sized amount of fluoride toothpaste helps strengthen enamel and prevent decay; supervise to avoid swallowing.
E. Toddlers’ teeth should be brushed twice daily, especially before bedtime.
Correct Answer is B
Explanation
. The nurse should check the medication label three times—when obtaining, preparing, and before administering.
B. Using two identifiers (e.g., name and date of birth) ensures correct patient identification per the Joint Commission National Patient Safety Goals.
C. Documentation should occur immediately after administration, not before, to avoid medication errors.
D. The accepted time frame is within 30 minutes of the scheduled time, not 3 hours.
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