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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
A. Referral to community services for support.
Referral to community services for support is an important part of the discharge plan for a client in preterm labor.Community services can provide education, counseling, home visits, and other resources to help the client cope with preterm labor and prevent complications.
B. Encouragement to smoke in moderation.Statement is wrong because smoking is harmful for the unborn baby and can increase the risk of preterm labor.Smoking should be avoided completely during pregnancy and the client should be advised to quit or seek help to quit.
C. Instructions for heavy lifting and strenuous exercise.Statement is wrong because heavy lifting and strenuous exercise can trigger contractions and worsen preterm labor.The client should be instructed to rest as much as possible and avoid activities that may cause uterine irritation or bleeding.
D. Recommendation to avoid kangaroo care.Statement is wrong because kangaroo care, or skin-to-skin contact with the baby, is beneficial for both the mother and the baby after birth.Kangaroo care can help regulate the baby’s temperature, heart rate, breathing, and blood sugar levels, as well as promote bonding, breastfeeding, and infection prevention.The client should be encouraged to practice kangaroo care as soon as possible after delivery.
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