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

Answer and Explanation

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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Correct Answer is A

Explanation

History of urinary tract infections.According to the Mayo Clinic, untreated vaginal infections, such as urinary tract infections or sexually transmitted infections, are risk factors for preterm labor.

These infections can cause inflammation and irritation of the cervix, which can trigger contractions and cervical dilation.

Choice B is wrong because maternal age of 25 years is not a risk factor for preterm labor.In fact, women younger than 18 or older than 35 are more likely to have a preterm delivery.

Choice C is wrong because singleton pregnancy is not a risk factor for preterm labor.On the contrary, being pregnant with twins, triplets, or more (called "multiple gestations") is associated with a higher risk of preterm labor and birth.

Choice D is wrong because cervical length of 3 cm is not a risk factor for preterm labor.A short cervix (less than 2.5 cm) or a cervix that shortens in the second trimester instead of the third trimester is a risk factor for preterm delivery.A normal cervical length ranges from 3 to 5 cm during pregnancy.

A. Monitor vital signs and neurological status frequently B. Administer antibiotics as prescribed C. Elevate the head of the bed to 30 degrees D. Provide supplemental oxygen as needed

Correct Answer is A

Explanation

Monitor vital signs and neurological status frequently.

This is because intraventricular hemorrhage (IVH) is a common and serious complication of prematurity that can lead to hydrocephalus, cerebral palsy, and developmental delays.Monitoring vital signs and neurological status can help detect changes in intracranial pressure, bleeding, and infection.

Choice B is wrong because antibiotics are not indicated for IVH unless there is evidence of infection.

Choice C is wrong because elevating the head of the bed to 30 degrees can increase the risk of IVH by reducing cerebral perfusion pressure and causing venous congestion.

Choice D is wrong because supplemental oxygen is not recommended for IVH unless there is hypoxia or respiratory distress.Excessive oxygen can cause oxidative stress and vasoconstriction, which can worsen IVH.

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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?

Nursing Test Bank

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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?