Following a minor motor vehicle collision, a client at 36-weeks gestation is brought to the emergency center.She is lying supine on a backboard, is awake, and denies any complaints.
Her blood pressure is 80/50 mmHg and her heart rate is 130 beats/minute.
Which action should the nurse implement first?

Infuse 1,000 mL normal saline using a large bore IV.

Obtain a blood sample for a complete blood count.

Tilt the backboard sideways to displace the uterus laterally.

Palpate the abdomen for contractions.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Infusing 1,000 mL normal saline using a large bore IV is a good response to increase the client's blood volume and improve blood pressure, but it should not be the first action. The immediate priority is to relieve the compression of the inferior vena cava caused by the gravid uterus, which is decreasing blood return to the heart and causing hypotension.

Choice B rationale

Obtaining a blood sample for a complete blood count is important for assessing the client's overall health and identifying any possible complications, but it does not address the immediate life-threatening issue of hypotension caused by the gravid uterus compressing the inferior vena cava.

Choice C rationale

Tilting the backboard sideways to displace the uterus laterally is the correct first action. This maneuver helps to relieve the compression of the inferior vena cava by the gravid uterus, thereby improving blood return to the heart, increasing cardiac output, and normalizing blood pressure.

Choice D rationale

Palpating the abdomen for contractions is important to assess for potential labor or uterine irritability, but it does not address the immediate need to relieve the compression of the inferior vena cava causing hypotension.

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Correct Answer is B

Explanation

Choice A rationale: Increasing the infusion rate of magnesium sulfate without medical approval is not appropriate. The prescribed rate should be followed unless the provider orders a change.

Choice B rationale: Assessing the client’s deep tendon reflexes and respiratory rate before administering magnesium sulfate is crucial. Magnesium sulfate can depress the central nervous system and respiratory function, so baseline assessments are necessary to identify any adverse effects early.

Choice C rationale: Stopping the infusion for variable decelerations is not the initial step. Variable decelerations may need to be addressed, but it is not the priority action before starting magnesium sulfate.

Choice D rationale: Administering an antihypertensive medication is important if the blood pressure remains elevated, but it is not specified as required before starting magnesium sulfate.

A. Gravida 4. B. Gravida 3. C. Gravida 5. D. Gravida 2.

Correct Answer is A

Explanation

Choice A rationale

Gravidity refers to the total number of times a woman has been pregnant, regardless of the outcome. This client has had one full-term infant, one premature infant, and one miscarriage, plus the current pregnancy, making a total of four pregnancies.

Choice B rationale

Gravidity is not determined by the number of live births. This client has had more than three pregnancies, so Gravida 3 is incorrect.

Choice C rationale

Gravidity does not count the number of live births and miscarriages separately. It counts the total number of pregnancies, making Gravida 5 incorrect in this context.

Choice D rationale

Gravida 2 would only apply if the client had been pregnant twice, which is not the case here.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a 34-year-old female client in the labor and delivery unit. Exhibits The nurse prepares to initiate magnesium sulfate therapy for the client. What is the priority nursing action?

Correct Answer is B

Explanation

When reading the obstetrical history of a client who is currently at 36 weeks gestation, the nurse notes that she has had one full-term infant, one premature infant born at 32 weeks gestation that survived, and one miscarriage.Which is this client's gravidity?

Correct Answer is A

Explanation

During a prenatal visit, a client at 30 weeks gestation reports persistent heartburn during the past two weeks.The nurse notes the client has 3+ bilateral, pitting, pedal edema.Which action should the nurse implement?

A client at 37 weeks gestation presents to labor and delivery with contractions every 2 minutes.The nurse observes several shallow, small vesicles on her pubis, labia, and perineum.The nurse should recognize the client is exhibiting symptoms of which condition?

A full-term infant is admitted to the newborn nursery 2 hours after delivery.The delivery record indicates the mother is positive for human immunodeficiency virus (HIV) and received zidovudine intravenously during labor. Which action should the nurse implement?

After two miscarriages, a client is instructed to increase her daily intake of foods that includes folic acid.The client does not like green leafy vegetables and states she is allergic to soy. Which food should the nurse suggest that the client eat to obtain folic acid?

A client who suspects she is pregnant tells the nurse she has a peptic ulcer that is being treated with misoprostol, a synthetic prostaglandin E drug.How should the nurse respond?