The nurse is continuing to care for the client.
A provider admits a client to the inpatient obstetrics unit and writes several prescriptions based on the client’s condition. Which action should the nurse perform first?
Evaluating the fetal heart rate tracing.
Obtaining 24-hour urine collection.
Administering acetaminophen PO (by mouth). Select from Options 2.
Administering magnesium sulfate IV (intravenously).
Administering betamethasone IM (intramuscularly).
Inserting an indwelling urinary catheter.
The Correct Answer is A
Choice A rationale: Evaluating the fetal heart rate tracing is the most critical action in this scenario. The client is at 31 weeks of gestation and reports decreased fetal movement, which could indicate fetal distress. The nurse should first assess the fetal heart rate tracing to ensure the fetus is not in distress. Normal fetal heart rate is between 110 and 160 beats per minute.
Choice B rationale: Obtaining a 24-hour urine collection is important for assessing proteinuria, a sign of preeclampsia, but it is not the most immediate concern. The nurse can initiate this after ensuring the fetus is not in distress.
Choice C rationale: Administering acetaminophen PO (by mouth) can help relieve the client’s headache, but it is not the most immediate concern. The nurse can administer this medication after ensuring the fetus is not in distress and initiating other prescribed treatments.
Choice D rationale: Administering magnesium sulfate IV (intravenously) can prevent seizures in clients with preeclampsia. However, before administering this medication, the nurse should ensure that the fetus is not in distress.
Choice E rationale: Administering betamethasone IM (intramuscularly) can help accelerate fetal lung maturity in case of preterm labor. However, before administering this medication, the nurse should ensure that the fetus is not in distress.
Choice F rationale: Inserting an indwelling urinary catheter can help monitor urine output, which is important for clients receiving magnesium sulfate because oliguria can be a sign of magnesium toxicity. However, before inserting the catheter, the nurse should ensure that the fetus is not in distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
A heart rate of 140/min is not a specific indicator of desmopressin effectiveness in a child with diabetes insipidus. The effectiveness of desmopressin is primarily evaluated based on the reduction in excessive urination and thirst associated with the condition. Monitoring heart rate is essential in certain situations but is not a direct measure of desmopressin efficacy in managing diabetes insipidus.
Choice B rationale:
Cessation of nocturnal enuresis (bedwetting) is a significant indication that desmopressin, an antidiuretic hormone, is effective. One of the main symptoms of diabetes insipidus is excessive urination, including during the night, leading to bedwetting. When desmopressin effectively reduces urine production, patients often experience improvement in these symptoms, including the cessation of nocturnal enuresis.
Choice C rationale:
Capillary refill of 3 seconds is a measurement used to assess peripheral perfusion and circulatory status. While it is essential to monitor capillary refill in pediatric patients, especially in cases of dehydration or circulatory compromise, it is not a specific indicator of desmopressin effectiveness in managing diabetes insipidus. Capillary refill time is more relevant in the assessment of cardiovascular function and fluid status.
Choice D rationale:
The absence of hypoglycemic episodes is not a direct indicator of desmopressin effectiveness. Diabetes insipidus is unrelated to blood glucose levels, as it involves the dysregulation of water balance due to insufficient antidiuretic hormone. While it is essential to monitor blood glucose levels in patients with diabetes mellitus, it is not relevant to assessing the effectiveness of desmopressin in treating diabetes insipidus.
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale: Requesting additional information about the caller's relationship to the client does not ensure the caller's identity is verified, and it could still result in a breach of confidentiality.
Choice B rationale: Providing a general update about the client's condition over the telephone is not appropriate, as it could breach the client's confidentiality.
Choice C rationale: Referring the family member to the client's provider for the update respects confidentiality and ensures that information is only provided to authorized individuals, maintaining the client's privacy.
Choice D rationale: Encouraging the family member to contact the client directly for information ensures that the client has control over their own information and maintains confidentiality. This action respects the client's privacy and autonomy.
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