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
Explanation
A. Percussion is performed before palpation but after auscultation to prevent altering bowel sounds.
B. Palpation is the final step in abdominal assessment because it can stimulate bowel activity, changing the characteristics of bowel sounds. The correct sequence is: Inspection → Auscultation → Percussion → Palpation.
C. Auscultation occurs before percussion and palpation to assess bowel sounds accurately without interference.
D. Inspection is always performed first to observe for contour, symmetry, scars, or distention before any manipulation of the abdomen.
Correct Answer is D
Explanation
A. Butorphanol (an opioid agonist-antagonist) can cause respiratory depression in the newborn if administered close to delivery; not safe during second-stage labor.
B. Naloxone is not a pain management drug, it reverses opioid effects and would not provide analgesia.
C. Spinal anesthesia is typically used for cesarean delivery, not for a woman already pushing in the second stage of labor.
D. A pudendal block provides local perineal anesthesia for the late second stage of labor, episiotomy, or delivery. It does not affect maternal consciousness or fetal status, making it safe during pushing.
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