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 B
Explanation
A. Placement is confirmed via chest X-ray, not CT scan.
B. The procedure is performed using strict sterile technique—the provider wears a mask, sterile gloves, and gown to prevent infection.
C. The client’s head is lowered (Trendelenburg position) to promote venous filling and reduce the risk of air embolism.
D. Local anesthesia is used, not general anesthesia.
Correct Answer is B
Explanation
A. This reflects acceptance and adaptation, not body image disturbance.
B. Avoiding mirrors or lights when undressing indicates embarrassment, shame, or distress about appearance, which are classic signs of disturbed body image.
C. Willingness to join a support group suggests positive coping and readiness for adjustment.
D. Expressing interest in reconstructive surgery shows hope and proactive adaptation, not negative body image.
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