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. Paracentesis is indicated for the removal of ascitic fluid, not for postoperative gas distention. It is inappropriate after a laparoscopic procedure unless ascites or fluid accumulation is confirmed.
B. The prone position can impede ventilation and increase abdominal pressure; it does not help relieve gas distention.
C. While a rectal suppository may aid bowel movement, it is not the first-line intervention for postoperative gas pain or distention.
D. Assisting the client to ambulate promotes the passage of flatus and relieves gas pain resulting from insufflation of carbon dioxide used during laparoscopy. Early ambulation enhances bowel motility and reduces abdominal distention.
Correct Answer is C
Explanation
A. Diuretics should be taken in the morning to reduce nighttime urination. Evening dosing increases nocturia and sleep disruption.
B. Cranberry juice acidifies urine and may prevent infection; it is not contraindicated for incontinence unless otherwise prescribed.
C. Scheduled voiding every 2–3 hours helps retrain bladder muscles, increase bladder capacity, and reduce urgency/frequency episodes. Over time, the intervals are gradually lengthened as control improves.
D. Severe fluid restriction can lead to concentrated urine, bladder irritation, and increased infection risk. Adequate hydration supports urinary tract health.
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