The nurse continues to care for the client.

Exhibits

Click to highlight the findings that indicate improvement in the client's condition. To deselect a finding, click on the finding again.

Assessment	Findings
Nurses' Notes	Client rates lower back pain a 0 on a scale from 0 to 10. No reports of vaginal discharge. Membranes intact No uterine contractions noted. FHR baseline 138, minimal variability. No further reports of burning with urination.
Laboratory Results	WBC 12,000/mm3 (5000 to 10000/mm3) Platelet count 188000/mm3 (150000 to 400000/mm3)
Vital Signs	Temperature 37.1oC (98.7 oF) Blood pressure 120/78 mmHg

After notifying the provider, the nurse should first administer oxygen at 2L/min via nasal cannula and then administer sublingual nitroglycerin.

Rationale:

Step 1: Administer Oxygen at 2L/min via Nasal Cannula

The client's oxygen saturation has dropped from 97% to 92% on room air, which indicates potential myocardial oxygen demand exceeding supply. Oxygen therapy helps improve myocardial oxygenation, which is crucial for clients with suspected acute coronary syndrome (ACS).

Step 2: Administer Sublingual Nitroglycerin

The client’s chest pain has worsened (increased from 4/10 to 7/10) and is associated with shortness of breath, which suggests possible myocardial ischemia. Nitroglycerin causes vasodilation, reducing myocardial oxygen demand and improving coronary perfusion.

It is a first-line treatment for suspected angina or acute coronary syndrome (ACS).

Incorrect Options

Step 1:

Prepare the client for cardiac catheterization: While a catheterization may be necessary, immediate interventions (oxygen, nitroglycerin) take priority before an invasive procedure.

Request a prescription for an increase in statin medication: Adjusting statins is a long-term strategy; it does not address the acute issue of chest pain and shortness of breath.

Step 2:

Request a prescription for a beta-blocker: Beta-blockers reduce heart rate and myocardial oxygen demand, but nitroglycerin provides more immediate relief for chest pain.

Check a STAT cardiac troponin: A repeat troponin may be necessary, but the initial focus is on stabilizing the client’s oxygenation and relieving chest pain.

A. Polyhydramnios (excess amniotic fluid) is not associated with placenta previa.
B. Nausea is not a typical symptom of placenta previa.
C. Placenta previa is a condition where the placenta partially or completely covers the cervix, leading to painless vaginal bleeding (spotting or heavy bleeding).
D. Uterine tenderness is more common with placental abruption, not placenta previa.