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The nurse is continuing to care for the client.

Exhibits

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

followed by .
Answer and Explanation

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.


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Related Questions

Correct Answer is B

Explanation

A. Immunosuppressed clients should have limited staff exposure to reduce the risk of infection. Rotating caregivers increases exposure to pathogens.

B. Inspecting the mouth frequently allows early detection of mucositis, ulcerations, or fungal infections such as Candida albicans, which are common in immunocompromised clients. Prompt intervention can prevent systemic infection.

C. Vital signs should be monitored more frequently (every 4 hours) because infection may develop rapidly and may present only as subtle changes in temperature or heart rate.

D. Fresh fruits and raw vegetables may carry pathogens and should be avoided in immunosuppressed clients. Only cooked or canned foods are safe.

Correct Answer is C

Explanation

A. Red meat are high in saturated fat and cholesterol, which can contribute to hypertension and atherosclerosis.

B. Cheese often contains high sodium and saturated fats, which can raise blood pressure.

C. Fish, particularly fatty fish such as salmon or mackerel, are rich in omega-3 fatty acids, which reduce triglyceride levels, decrease inflammation, and help lower blood pressure. Lean fish also provides a healthy protein source with minimal saturated fat.

D. While canned black beans are high in fiber and beneficial for heart health, canned varieties often contain high sodium, which may worsen hypertension unless rinsed or replaced with low-sodium options.

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