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The nurse is continuing to care for the client.

Exhibits

Complete the following sentence by using the list of options

The provider has admitted the client to the inpatient obstetric unit and written prescriptions based on the client's condition.

The action the nurse should take first is

followed by .
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}

Rationale for Correct Choices:

  • Evaluating the fetal heart rate tracing: The client’s report of decreased fetal movement and severe hypertension raises concern for fetal compromise. Immediate fetal assessment ensures the fetus is tolerating the intrauterine environment, especially before administering medications like magnesium sulfate.
  • Administering magnesium sulfate IV: This is prescribed to prevent eclampsia, given the client’s severely elevated BP, hyperreflexia, and proteinuria. After confirming fetal status, seizure prophylaxis should be initiated without delay.

Rationale for Incorrect Choices:

  • Administering acetaminophen PO: Although ordered for headache, the symptom is a manifestation of severe preeclampsia. Treating it symptomatically without addressing its cause could delay necessary critical interventions.
  • Obtaining a 24-hour urine collection: Useful for confirming the extent of proteinuria, but not immediately necessary for clinical decision-making given existing positive findings.
  • Inserting an indwelling urinary catheter: This supports fluid monitoring during magnesium therapy, but fetal assessment and seizure prevention take precedence.
  • Administering betamethasone IM: Important for fetal lung development in preterm pregnancies, but it is not the immediate priority when there is a high risk for seizure or fetal distress.


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Related Questions

Correct Answer is B

Explanation

Rationale:

A. A client who has an open compound fracture of the humerus: This injury requires surgical intervention and has a moderate to high risk of complications. It is typically classified as yellow, indicating delayed care is acceptable but not minor.

B. A client who has multiple facial lacerations: These are superficial injuries that can be treated with simple wound care and suturing. The client is likely stable and ambulatory, fitting the criteria for a green tag, which denotes minor injuries requiring minimal care.

C. A client who has a puncture wound in the right lower lung: This suggests potential internal injury and respiratory compromise. Such a case is urgent and unstable, requiring immediate intervention, and would be tagged red for immediate treatment.

D. A client who has full-thickness burns over the lower extremities: Full-thickness burns covering a large area are life-threatening and resource-intensive to manage. Depending on the extent, this may fall under red or black, depending on survivability and available resources.

Correct Answer is C

Explanation

Rationale:

A. "Rinse your mouth with an alcohol-based mouthwash.": Alcohol-based mouthwashes can further irritate the mucous membranes, worsen oral discomfort, and dry the oral tissues, especially in clients with mucositis or candidiasis common in AIDS.

B. "Eat foods served at hot temperatures.": Hot foods can aggravate oral sores and cause more pain or tissue damage. Cool or room-temperature foods are typically better tolerated when the mouth is sore.

C. "Use ice chips to numb your mouth.": Ice chips can provide temporary relief by numbing oral tissues, reducing inflammation, and making eating more comfortable. This is a helpful, non-pharmacologic intervention for oral pain.

D. "Add salt to season foods.": Salt can irritate open or inflamed oral tissues and worsen the discomfort. Bland, soft foods without strong seasonings are usually better tolerated in cases of mouth soreness.

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