A nurse is caring for a client who is pregnant.
Complete the following sentence using the list of options.
The provider has admitted the client to an inpatient obstetrics unit and written prescriptions based on the client’s condition. The first action the nurse should take is
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
The first action the nurse should take is evaluating the fetal heart rate tracing, followed by administering labetalol IV.
Rationale for Correct Answers:
Evaluating the fetal heart rate tracing first is the priority because the client is at 31 weeks of gestation with severe preeclampsia and reported decreased fetal movement. Fetal assessment is time-sensitive; identifying any signs of fetal distress is critical to prevent hypoxia or other complications.
Administering labetalol IV is the next priority to manage the client’s severe hypertension (BP 166/110 mm Hg), which places both mother and fetus at risk for complications such as stroke, placental abruption, or fetal compromise.
Rationale for Incorrect options:
Administering acetaminophen PO addresses maternal headache but does not prevent immediate maternal or fetal complications, so it is lower priority.
Obtaining a 24-hour urine collection, betamethasone, and lactated Ringer’s are important interventions but are secondary to assessing fetal status and stabilizing maternal blood pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Refer the adolescent to a local mental health clinic: While emotional support may be beneficial, the client’s primary concern is financial, not psychological. This may be appropriate later but not the priority.
B. Assist theadolescent in applying for Medicaid: Medicaid provides financial assistance for prenatal, delivery, and infant care for low-income individuals. Helping the adolescent access this resource promotes maternal and fetal health by ensuring adequate prenatal care and support services.
C. Contact the adolescent's parent for assistance: The nurse must maintain confidentiality unless the adolescent gives consent. In most regions, pregnant minors can consent to their own pregnancy-related care.
D. Advise the adolescent to place the newborn for adoption: This is a non-therapeutic and directive response. The nurse should support the adolescent’s autonomy and provide resources for informed decision-making, not impose personal opinions.
Correct Answer is ["A","C","D"]
Explanation
Rationale:
A. Closing the door helps contain radiation and protect staff and visitors from exposure.
B. A semi-private room is contraindicated; the client must be in a private room to protect others from radiation exposure.
C. Wearing a lead apron during direct care reduces exposure to scatter radiation. The nurse should also avoid standing directly at the radiation source.
D. Limiting visitors to 30 minutes per day minimizes radiation exposure time. The principle of "time, distance, and shielding" guides radiation safety.
E. Pregnant visitors should not enter the client’s room at all, as fetal tissue is highly sensitive to radiation.
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