A nurse is caring for a client who is at 32 weeks of gestation and reports lower abdominal cramping.
Which of the following actions should the nurse take first?
Assess the client’s vital signs
Perform a sterile vaginal exam
Administer tocolytic medication
Monitor the fetal heart rate
The Correct Answer is A
Assess the client’s vital signs.
The nurse should first assess the client’s vital signs to determine the severity of the situation and identify any signs of infection, bleeding, or shock.
The nurse should also monitor the fetal heart rate to assess fetal well-being.
Choice B is wrong because a sterile vaginal exam is not indicated for a client who reports lower abdominal cramping and may increase the risk of infection or rupture of membranes.
Choice C is wrong because administering tocolytic medication is not the first action the nurse should take.
Tocolytic medication may be used to inhibit uterine contractions and prolong pregnancy, but only after assessing the client’s and fetus’s condition and obtaining a prescription from the provider.
Choice D is wrong because monitoring the fetal heart rate is not the first action the nurse should take.
Monitoring the fetal heart rate is important to assess fetal well-being, but it does not take priority over assessing the client’s vital signs.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Indomethacin is a nonsteroidal anti-inflammatory drug (NSAID) that can cause renal impairment and elevated serum creatinine levels in both the mother and the fetus.This can lead to oligohydramnios, reduced fetal urine output, and fetal renal failure.
Therefore, the nurse should monitor the serum creatinine levels of the client and the fetus as a potential complication of indomethacin.
Choice A is wrong because indomethacin does not affect the platelet count.It may increase the risk of bleeding due to its antiplatelet effect, but it does not cause thrombocytopenia.
Choice C is wrong because indomethacin does not cause anemia or decrease the hematocrit.It may cause gastrointestinal bleeding or ulceration, which could lead to anemia, but this is not a common or direct effect of the medication.
Choice D is wrong because indomethacin does not cause hyperkalemia or increase the serum potassium levels.It may cause hyponatremia due to its effect on renal sodium excretion, but it does not affect potassium balance.
Correct Answer is A
Explanation
Indomethacin is a nonsteroidal anti-inflammatory drug (NSAID) that helps close the ductus arteriosus, a blood vessel connecting two arteries of the heart (aorta and pulmonary artery) in fetus.This drug is effective only among premature babies.
Choice B.Prostaglandin E1 is wrong because it is used to keep the ductus arteriosus open in some congenital heart defects that require surgery.
Choice C.Furosemide is wrong because it is a diuretic that reduces fluid retention and blood pressure, but does not affect the ductus arteriosus.
Choice D.Digoxin is wrong because it is a cardiac glycoside that strengthens the heart muscle contractions and regulates the heart rhythm, but does not affect the ductus arteriosus.
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