The nurse is continuing to care for the client.
A provider admits a client to the inpatient obstetrics unit and writes several prescriptions based on the client’s condition. Which action should the nurse perform first?
Evaluating the fetal heart rate tracing.
Obtaining 24-hour urine collection.
Administering acetaminophen PO (by mouth). Select from Options 2.
Administering magnesium sulfate IV (intravenously).
Administering betamethasone IM (intramuscularly).
Inserting an indwelling urinary catheter.
The Correct Answer is A
Choice A rationale: Evaluating the fetal heart rate tracing is the most critical action in this scenario. The client is at 31 weeks of gestation and reports decreased fetal movement, which could indicate fetal distress. The nurse should first assess the fetal heart rate tracing to ensure the fetus is not in distress. Normal fetal heart rate is between 110 and 160 beats per minute.
Choice B rationale: Obtaining a 24-hour urine collection is important for assessing proteinuria, a sign of preeclampsia, but it is not the most immediate concern. The nurse can initiate this after ensuring the fetus is not in distress.
Choice C rationale: Administering acetaminophen PO (by mouth) can help relieve the client’s headache, but it is not the most immediate concern. The nurse can administer this medication after ensuring the fetus is not in distress and initiating other prescribed treatments.
Choice D rationale: Administering magnesium sulfate IV (intravenously) can prevent seizures in clients with preeclampsia. However, before administering this medication, the nurse should ensure that the fetus is not in distress.
Choice E rationale: Administering betamethasone IM (intramuscularly) can help accelerate fetal lung maturity in case of preterm labor. However, before administering this medication, the nurse should ensure that the fetus is not in distress.
Choice F rationale: Inserting an indwelling urinary catheter can help monitor urine output, which is important for clients receiving magnesium sulfate because oliguria can be a sign of magnesium toxicity. However, before inserting the catheter, the nurse should ensure that the fetus is not in distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Using a 12-point font when printing written materials is helpful for readability, especially for individuals with visual impairments. However, this action alone does not necessarily promote meaningful learning. The content and presentation style are equally important.
Choice B rationale:
Presenting information using abstract concepts can be confusing, especially for older adults. Using concrete examples and simple language facilitates better understanding. Abstract concepts are more challenging to grasp, especially for individuals who might be experiencing cognitive decline.
Choice C rationale:
Connecting new information with the client's past experiences enhances learning and retention. Relating new knowledge to familiar situations or memories helps create cognitive associations, making it easier for the client to understand and remember the information. This technique is particularly effective in promoting learning among older adults.
Choice D rationale:
Speaking loudly when addressing the client is unnecessary and can be perceived as rude or patronizing. Clear and audible speech is essential, but shouting or raising the volume excessively is not respectful and does not enhance the learning experience.
Correct Answer is C
Explanation
Choice A rationale:
Expressing concern about another shift's holiday hours does not necessarily involve interpersonal conflict. It may reflect dissatisfaction but doesn't involve direct conflict between individuals.
Choice B rationale:
A personal difficulty with caring for clients who have HIV could be a challenge for the nurse, but it's not an example of interpersonal conflict. It represents a personal struggle rather than a conflict with another individual.
Choice C rationale:
Insulting comments directed at a nurse by another nurse represent interpersonal conflict. Such behavior involves a direct clash of personalities and can create a hostile work environment, affecting the nurse's well-being and job performance. Addressing this type of conflict is crucial for maintaining a positive work atmosphere.
Choice D rationale:
Submitting a complaint about another department's handoff reporting might indicate dissatisfaction or concerns about workflow, but it's not necessarily an interpersonal conflict. It could be a communication issue or a difference in professional opinion rather than a direct clash between individuals.
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