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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 C

Explanation

Rationale:

A. "Opioids should not be given to older adults.": Opioids can be given to older adults when necessary, but with caution. The dose may need adjustment due to age-related changes in metabolism and increased sensitivity, not outright avoidance.

B. "Pain perception is decreased in older adult clients.": Pain perception does not decrease with age. Older adults may have conditions that affect communication or cognition, but their ability to feel pain remains intact, and they can still experience significant discomfort.

C. "Older adults report pain less frequently than younger clients.": Older adults often underreport pain due to beliefs that pain is a normal part of aging or fear of treatment consequences. This makes active assessment and trust-building essential in managing their pain effectively.

D. "Older adults require higher doses of pain medication.": Older adults typically require lower or more carefully titrated doses due to slower metabolism, decreased renal clearance, and heightened drug sensitivity, especially to central nervous system effects.

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

Explanation

Rationale for Correct Choices:

  • Reye's syndrome: The toddler's worsening condition including vomiting, lethargy, and altered consciousness after a viral illness (influenza A) is consistent with Reye’s syndrome, which affects the liver and brain. The progression from mild viral symptoms to neurologic decline without respiratory compromise further supports this diagnosis.
  • Aspirin administration: Giving aspirin during a viral illness in children is a well-known precipitant of Reye’s syndrome. The caregivers' report of alternating aspirin with acetaminophen confirms the exposure necessary to trigger the condition in a susceptible child.

Rationale for Incorrect Choices:

  • Gastroenteritis: While vomiting is a feature of gastroenteritis, the absence of diarrhea and the presence of neurologic changes like lethargy and poor responsiveness make this unlikely. Additionally, the clear vomiting and lack of fluid intake without prior GI focus suggest another etiology.
  • Bronchitis: Bronchitis typically causes a productive cough with wheezing, chest discomfort, and possible fever. This toddler's lungs are clear with a nonproductive cough, and neurologic signs are not typical of bronchitis.
  • Acetaminophen administration: Acetaminophen is safe and commonly used to treat fever in toddlers. It is not associated with hepatic encephalopathy or neurologic complications seen in this scenario.
  • Oseltamivir administration: Though oseltamivir may cause gastrointestinal side effects like nausea or vomiting, it does not explain the altered mental status and lethargy. It is also unlikely to cause such a significant clinical deterioration on its own.

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