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 {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"}}
No explanation
Correct Answer is C
Explanation
Answer is: c. Protect the IV bag from exposure to light.
Explanation: Nitroprusside degrades when exposed to light, so the nurse should protect the IV bag from light exposure to maintain the medication's potency and effectiveness in treating the client's severe hypertension.
Choice a. is wrong because calcium gluconate is used as an antidote for magnesium sulfate toxicity. Although it may be kept on hand in some facilities, it is not directly related to the administration of nitroprusside.
Choice b. is wrong because attaching an inline filter is not necessary when administering nitroprusside. It is more relevant for medications that require filtration, such as certain chemotherapeutic agents.
Choice d. is wrong because monitoring blood pressure every 2 hours is not frequent enough for a client receiving nitroprusside. The nurse should monitor the client's blood pressure more frequently, such as every 5 to 15 minutes, depending on facility policies and the client's condition.
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