A client at 10-weeks gestation calls the clinic reporting a low-grade fever, moderate cramping, and heavy bright-red bleeding.
What advice should the nurse give the client?

Take acetaminophen.

Come in for an immediate evaluation.

Monitor the flow of the vaginal bleeding.

Rest in a supine position at home.

Answer and Explanation

The Correct Answer is B

Choice A rationale

While acetaminophen can help reduce fever, it does not address the underlying cause of the client’s symptoms. Moreover, self-medication without proper medical advice can potentially harm the pregnancy.

Choice B rationale

The client’s symptoms of low-grade fever, moderate cramping, and heavy bright-red bleeding could indicate a serious condition such as a miscarriage or an ectopic pregnancy. Therefore, immediate medical evaluation is necessary.

Choice C rationale

While monitoring the flow of vaginal bleeding can provide useful information, it does not address the immediate need for medical evaluation given the client’s symptoms.

Choice D rationale

Resting at home might not be the best advice given the severity of the client’s symptoms. Immediate medical evaluation is necessary.

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Correct Answer is B

Explanation

Choice A rationale

Administering oxygen via facemask is a common intervention for variable decelerations, but it is not the first action that should be taken.

Choice B rationale

Changing the client’s position is the recommended first action for variable decelerations. Repositioning the mother, such as moving her to a lateral or knee-chest position, can relieve potential cord compression and improve fetal oxygenation.

Choice C rationale

Turning off the oxytocin infusion is another intervention for variable decelerations, but it is not the first action that should be taken.

Choice D rationale

Assessing cervical dilation is not the first action that should be taken in response to variable decelerations.

A. Call the healthcare provider. B. Encourage the client to void. C. Administer ibuprofen 800 mg by mouth. D. Increase the intravenous fluid to 150 mL/hour.

Correct Answer is B

Explanation

Choice A rationale

While notifying the healthcare provider is important, it is not the first action to take. The nurse should first address the immediate issue of a potentially full bladder that could be displacing the uterus.

Choice B rationale

Encouraging the client to void can help if the bladder is full. A full bladder can displace the uterus and interfere with uterine contractions, leading to increased bleeding.

Choice C rationale

Administering ibuprofen can help with cramping, but it does not address the immediate issue of a potentially full bladder displacing the uterus.

Choice D rationale

Increasing the intravenous fluid rate is not the first action to take. The nurse should first address the immediate issue of a potentially full bladder displacing the uterus.

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A client at 10-weeks gestation calls the clinic reporting a low-grade fever, moderate cramping, and heavy bright-red bleeding.What advice should the nurse give the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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A client at 10-weeks gestation calls the clinic reporting a low-grade fever, moderate cramping, and heavy bright-red bleeding.
What advice should the nurse give the client?