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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Related Questions
Correct Answer is B
Explanation
Instruct the client to empty her bladder.This is because a full bladder can interfere with the insertion of the needle and increase the risk of injury to the bladder or the uterus.Emptying the bladder also reduces discomfort during the procedure.
Choice A is wrong because administering tocolytic medication to stop contractions is not necessary before amniocentesis.Tocolytic medication can have side effects and should only be used when there is a clear indication of preterm labor.
Choice C is wrong because obtaining informed consent from the client is not a nursing action, but a medical one.The nurse can assist in providing information and answering questions, but the final consent should be obtained by the doctor who will perform the procedure.
Choice D is wrong because monitoring fetal heart rate and activity is not a specific action before amniocentesis, but a routine part of prenatal care.Fetal heart rate and activity can be affected by many factors, such as maternal position, fetal sleep cycle, or maternal blood sugar level.
Monitoring them before amniocentesis does not provide any useful information for the procedure.
Correct Answer is B
Explanation
Prepare for an emergency cesarean section.This is because the client has pre-term labor that has not responded to tocolytic therapy, which are drugs that are used to delay delivery for a short time.The client’s cervix is dilated to 4 cm and she is experiencing regular contractions every 3 minutes, which are signs of active labor.The baby is at 33 weeks of gestation, which is premature and may have complications such as respiratory distress syndrome or bleeding in the brain.
Therefore, the client needs an emergency cesarean section to deliver the baby as soon as possible and prevent further risks.
Choice A is wrong because administering magnesium sulfate intravenously is a type of tocolytic therapy that the client has already failed.Magnesium sulfate may also have side effects such as nausea, vomiting, flushing, headache, and muscle weakness.
Choice C is wrong because placing the client in Trendelenburg position, which is lying on the back with the feet elevated above the head, is not recommended for preterm labor.This position may increase the risk of aspiration, decrease cardiac output, and impair gas exchange.
Choice D is wrong because administering antibiotics prophylactically is not indicated for preterm labor unless there is evidence of infection in the uterus or membranes.
Antibiotics may also cause allergic reactions or bacterial resistance
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