A nurse is assisting with the admission of a client who is at 8 weeks of gestation and has heavy vaginal bleeding. Which of the following actions should the nurse take?

Initiate an IV infusion of magnesium sulfate.

Administer antibiotics.

Request the RN perform a cervical examination.

Prepare for cesarean birth.

Answer and Explanation

The Correct Answer is C

Choice A:
Magnesium sulfate is a medication primarily used to prevent or manage seizures in women with preeclampsia or eclampsia, conditions characterized by high blood pressure and protein in the urine during pregnancy. It is not indicated for heavy vaginal bleeding in early pregnancy.
Administration of magnesium sulfate without a clear indication could potentially lead to adverse effects such as respiratory depression, decreased deep tendon reflexes, and cardiac arrhythmias.

Choice B:
Antibiotics are used to treat bacterial infections. While heavy vaginal bleeding can sometimes be a sign of infection, it is not the primary cause of bleeding in early pregnancy.
Indiscriminate use of antibiotics without a confirmed bacterial infection can contribute to antibiotic resistance and potentially mask the underlying cause of the bleeding.

Choice D:
Cesarean birth is a major surgical procedure that is typically reserved for situations where there is a risk to the mother or fetus, such as fetal distress, failure to progress in labor, or placental abruption.
It is not indicated as the first-line intervention for heavy vaginal bleeding in early pregnancy, as there are other less invasive diagnostic and management options available.

Choice C:
A cervical examination allows the healthcare provider to assess the condition of the cervix, including its dilation and effacement, as well as to potentially identify any sources of bleeding, such as cervical polyps or lesions.
This information is crucial in determining the appropriate course of management for the patient.
It can help differentiate between potential causes of bleeding, such as threatened miscarriage, inevitable miscarriage, or ectopic pregnancy.

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Correct Answer is D

Explanation

Choice A:
It is inaccurate to state that urinary frequency will continue throughout pregnancy in most cases. While it is a common symptom, it typically resolves by the end of the first trimester.
Suggesting that poor bladder tone is the cause of ongoing urinary frequency is not supported by evidence. This response may unnecessarily alarm a client who is already experiencing discomfort.

Choice B:
It is not recommended to advise a pregnant woman to decrease her fluid intake, especially during the first trimester when adequate hydration is crucial.
Restricting fluids can lead to dehydration, which can have negative consequences for both the mother and the fetus. While reducing fluid intake before bedtime might lessen nighttime urination, it does not address the underlying cause of urinary frequency.

Choice C:
While it is true that the duration of urinary frequency can vary among individuals, providing such an uncertain response may not be helpful to the client.
It is important to offer information that is both accurate and reassuring.

Choice D:
This response accurately conveys that urinary frequency is a common early pregnancy symptom that typically resolves by the end of the first trimester.
It also acknowledges that the symptom may return later in pregnancy, which helps to prepare the client for potential discomfort.
This response provides accurate information in a reassuring manner, making it the most appropriate choice.

Correct Answer is []

Explanation

Condition

A. Preeclampsia is the most likely condition the client is experiencing given the following:
- History of gestational diabetes and mild hypertension.
- Recent elevation in blood pressure.
- Preeclampsia is characterized by high blood pressure and can be associated with kidney involvement, as suggested by the increased blood pressure.

Actions

Administer prescribed antihypertensive medication: This is crucial for managing preeclampsia, as it helps lower blood pressure and prevent complications.
Monitor blood pressure and urine protein levels regularly: Essential for assessing the progression of preeclampsia and guiding treatment decisions. Monitoring helps track whether the condition is worsening or responding to treatment.

Parameters to Monitor

Blood pressure readings: These are directly related to the severity of preeclampsia and help assess if the treatment is effective.
Level of protein in urine: Elevated protein levels indicate kidney involvement, which is a common complication of preeclampsia.

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A nurse is assisting with the admission of a client who is at 8 weeks of gestation and has heavy vaginal bleeding. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in the prenatal clinic who is at 7 weeks of gestation. The client reports urinary frequency and asks the nurse if this will continue throughout her pregnancy. Which of the following responses by the nurse is appropriate?

Correct Answer is D

Explanation

Correct Answer is []

Explanation

Condition

Actions

Parameters to Monitor

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