The nurse is continuing to care for the client.
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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Temperature 36.8° C (98° F): This temperature is within the normal range and does not suggest a current or impending infection. It indicates stable thermoregulation in the postoperative period.
B. White blood cell count 8,000/mm³ (5,000 to 10,000/mm³): This WBC count falls within the normal reference range and does not reflect infection or inflammation. No abnormal immune response is indicated by this result.
C. Body mass index of 32: A BMI over 30 is classified as obesity, which increases the risk of poor wound healing and surgical site infections. Excess adipose tissue can impair circulation, oxygenation, and immune response at the wound site.
D. Blood glucose 90 mg/dL (74 to 106 mg/dL): This is a normal fasting glucose level and does not contribute to infection risk. Well-controlled glucose levels are favorable for wound healing and immune function.
Correct Answer is ["A","B","C","D","F","G"]
Explanation
Rationale:
A. Provide a low-stimulation environment: The client has a severe headache, 3+ proteinuria, and elevated BP, indicating severe preeclampsia. A quiet, low-light environment reduces the risk of seizure by limiting neurologic stimulation.
B. Maintain bed rest: Bed rest in a side-lying position improves uteroplacental blood flow and helps lower blood pressure. It also decreases metabolic demand, which is critical in hypertensive pregnancies.
C. Give antihypertensive medication: The BP readings (162/112 and 166/110 mm Hg) require immediate antihypertensive therapy to prevent cerebral hemorrhage, eclampsia, or placental abruption.
D. Obtain a 24-hr urine specimen: A 24-hour urine collection for protein is the gold standard for quantifying proteinuria and confirming the diagnosis of preeclampsia. While a dipstick of 3+ is a strong indicator, the 24-hour collection provides a definitive measurement.
E. Perform a vaginal examination every 12 hr: There are no contractions or signs of labor, so regular vaginal exams are not indicated and increase the risk of infection in a preterm pregnancy.
F. Monitor intake and output hourly: Decreased renal perfusion is a complication of preeclampsia. Hourly monitoring detects oliguria early and helps assess for fluid overload or worsening renal function.
G. Administer betamethasone: At 31 weeks, betamethasone is indicated to enhance fetal lung maturity due to risk of preterm delivery from severe maternal complications.
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