The nurse is continuing to care for the client.
The provider has admitted the client to the inpatient obstetrics 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":"A"}
Rationale for Correct Answers:
Evaluating the fetal heart rate tracing first is the priority because the client is at 31 weeks of gestation with severe preeclampsia and reported decreased fetal movement. Fetal assessment is time-sensitive; identifying any signs of fetal distress is critical to prevent hypoxia or other complications.
Administering labetalol IV is the next priority to manage the client’s severe hypertension (BP 166/110 mm Hg), which places both mother and fetus at risk for complications such as stroke, placental abruption, or fetal compromise.
Rationale for Incorrect options:
Administering acetaminophen PO addresses maternal headache but does not prevent immediate maternal or fetal complications, so it is lower priority.
Obtaining a 24-hour urine collection, betamethasone, and lactated Ringer’s are important interventions but are secondary to assessing fetal status and stabilizing maternal blood pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Cheyne-Stokes respirations: This is a common sign of approaching death but not necessarily an indication for pain medication.
B. Constricted pupils: This may indicate opioid use or neurological changes, not pain.
C. Mottled skin: Mottling occurs as circulation declines near the end of life, not specifically due to pain.
D. Restlessness: In palliative care, restlessness is often a sign of pain or discomfort, even if the client cannot verbalize pain. The nurse should administer prescribed pain medication to ensure comfort.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}
Explanation
The child is at highest risk for developing compartment syndrome evidenced by the child’s paresthesia.
Rationale:
Compartment syndrome is a serious complication of fractures, especially of the forearm, where swelling within the closed fascial compartments increases pressure and compromises blood flow and nerve function. The child’s paresthesia (tingling sensation) and slightly cool fingers indicate early neurovascular compromise, which is an early sign of compartment syndrome. While nondisplaced fractures have a lower risk than displaced fractures, close monitoring is essential because swelling and edema can still increase compartment pressure.
Other options like non-union or osteomyelitis are long-term complications, and physical damage is too nonspecific compared with the acute risk of compartment syndrome.
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