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 C
Explanation
A. Infants should not be given supplemental water, as it can interfere with nutrient intake and cause electrolyte imbalances.
B. Feedings should not be time-restricted; infants should nurse until they are satisfied to ensure they receive both foremilk (hydration) and hindmilk (calories and fat).
C. Breastfeeding should be on demand, whenever the infant shows hunger cues (e.g., rooting, sucking motions, hands to mouth). This helps establish milk supply and ensures adequate nutrition.
D. Feedings should alternate breasts to promote even milk production and prevent engorgement.
Correct Answer is ["C","D"]
Explanation
A. The nurse should approach from the front, not the side, and identify themselves before touching or speaking to avoid startling the client.
B. Very bright lighting can cause glare and worsen visual discomfort. Adequate, evenly distributed lighting is preferred.
C. Maintaining consistent placement of objects and furniture promotes independence and prevents falls. Unexpected changes can cause disorientation or injury.
D. Allowing additional time respects the client’s need to adapt and fosters independence. Rushing can cause frustration, accidents, or reduced self-esteem.
E. The nurse should announce presence verbally first, not by touch. Unexpected physical contact may frighten the client or cause anxiety.
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