A nurse is caring for a pregnant client at 36 weeks of gestation who reports low back pain and pelvic pressure.

Which intervention should the nurse implement first?

Administer a dose of tocolytic medication

Encourage the client to rest in a side-lying position

Assess fetal heart rate using a Doppler device

Assess vaginal discharge for any change

Answer and Explanation

The Correct Answer is C

Assess fetal heart rate using a Doppler device.

This is because low back pain and pelvic pressure at 36 weeks of gestation may indicate preterm labor, which can affect the fetal well-being. Therefore, the nurse should assess the fetal heart rate as a priority to determine if the fetus is in distress or not.

Choice A is wrong because tocolytic medication is used to stop uterine contractions, not to relieve low back pain and pelvic pressure. Choice B is wrong because resting in a side-lying position may help with blood circulation and reduce supine hypotensive syndrome, but it does not address the possible cause of low back pain and pelvic pressure. Choice D is wrong because assessing vaginal discharge for any change may indicate infection, rupture of membranes, or cervical dilation, but it is not as urgent as assessing fetal heart rate.

Some interventions for preventing and treating low back pain and pelvic pressure during pregnancy include exercise, water-based exercise, acupuncture, osteomanipulative therapy, craniosacral therapy, and pelvic support belts.

However, these interventions should be discussed with the health care provider before starting them.

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Correct Answer is A

Explanation

Assess the client’s vital signs.

The nurse should first assess the client’s vital signs to determine the severity of the situation and identify any signs of infection, bleeding, or shock.

The nurse should also monitor the fetal heart rate to assess fetal well-being.

Choice B is wrong because a sterile vaginal exam is not indicated for a client who reports lower abdominal cramping and may increase the risk of infection or rupture of membranes.

Choice C is wrong because administering tocolytic medication is not the first action the nurse should take.

Tocolytic medication may be used to inhibit uterine contractions and prolong pregnancy, but only after assessing the client’s and fetus’s condition and obtaining a prescription from the provider.

Choice D is wrong because monitoring the fetal heart rate is not the first action the nurse should take.

Monitoring the fetal heart rate is important to assess fetal well-being, but it does not take priority over assessing the client’s vital signs.

A. Decreased platelet count B. Increased serum creatinine C. Decreased hematocrit D. Increased serum potassium

Correct Answer is B

Explanation

Indomethacin is a nonsteroidal anti-inflammatory drug (NSAID) that can cause renal impairment and elevated serum creatinine levels in both the mother and the fetus.This can lead to oligohydramnios, reduced fetal urine output, and fetal renal failure.

Therefore, the nurse should monitor the serum creatinine levels of the client and the fetus as a potential complication of indomethacin.

Choice A is wrong because indomethacin does not affect the platelet count.It may increase the risk of bleeding due to its antiplatelet effect, but it does not cause thrombocytopenia.

Choice C is wrong because indomethacin does not cause anemia or decrease the hematocrit.It may cause gastrointestinal bleeding or ulceration, which could lead to anemia, but this is not a common or direct effect of the medication.

Choice D is wrong because indomethacin does not cause hyperkalemia or increase the serum potassium levels.It may cause hyponatremia due to its effect on renal sodium excretion, but it does not affect potassium balance.

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A nurse is caring for a pregnant client at 36 weeks of gestation who reports low back pain and pelvic pressure. Which intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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A nurse is caring for a pregnant client at 36 weeks of gestation who reports low back pain and pelvic pressure.

Which intervention should the nurse implement first?