The nurse is continuing to care for the client.
Complete the following sentence by using the list of options
The provider has admitted the client to the inpatient obstetric unit and written prescriptions based on the client's condition.
The action the nurse should take first is
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}
Rationale for Correct Choices:
- Evaluating the fetal heart rate tracing: The client’s report of decreased fetal movement and severe hypertension raises concern for fetal compromise. Immediate fetal assessment ensures the fetus is tolerating the intrauterine environment, especially before administering medications like magnesium sulfate.
- Administering magnesium sulfate IV: This is prescribed to prevent eclampsia, given the client’s severely elevated BP, hyperreflexia, and proteinuria. After confirming fetal status, seizure prophylaxis should be initiated without delay.
Rationale for Incorrect Choices:
- Administering acetaminophen PO: Although ordered for headache, the symptom is a manifestation of severe preeclampsia. Treating it symptomatically without addressing its cause could delay necessary critical interventions.
- Obtaining a 24-hour urine collection: Useful for confirming the extent of proteinuria, but not immediately necessary for clinical decision-making given existing positive findings.
- Inserting an indwelling urinary catheter: This supports fluid monitoring during magnesium therapy, but fetal assessment and seizure prevention take precedence.
- Administering betamethasone IM: Important for fetal lung development in preterm pregnancies, but it is not the immediate priority when there is a high risk for seizure or fetal distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Explanation
Rationale for Correct Choices:
- Reye's syndrome: The toddler's worsening condition including vomiting, lethargy, and altered consciousness after a viral illness (influenza A) is consistent with Reye’s syndrome, which affects the liver and brain. The progression from mild viral symptoms to neurologic decline without respiratory compromise further supports this diagnosis.
- Aspirin administration: Giving aspirin during a viral illness in children is a well-known precipitant of Reye’s syndrome. The caregivers' report of alternating aspirin with acetaminophen confirms the exposure necessary to trigger the condition in a susceptible child.
Rationale for Incorrect Choices:
- Gastroenteritis: While vomiting is a feature of gastroenteritis, the absence of diarrhea and the presence of neurologic changes like lethargy and poor responsiveness make this unlikely. Additionally, the clear vomiting and lack of fluid intake without prior GI focus suggest another etiology.
- Bronchitis: Bronchitis typically causes a productive cough with wheezing, chest discomfort, and possible fever. This toddler's lungs are clear with a nonproductive cough, and neurologic signs are not typical of bronchitis.
- Acetaminophen administration: Acetaminophen is safe and commonly used to treat fever in toddlers. It is not associated with hepatic encephalopathy or neurologic complications seen in this scenario.
- Oseltamivir administration: Though oseltamivir may cause gastrointestinal side effects like nausea or vomiting, it does not explain the altered mental status and lethargy. It is also unlikely to cause such a significant clinical deterioration on its own.
Correct Answer is C
Explanation
Rationale:
A. A small area rug is placed at the front door: Area rugs increase the risk of falls, especially in older adults or clients with mobility issues. Rugs should be removed or secured with non-slip backing to prevent tripping hazards at entrances and high-traffic areas.
B. The water heater is set at 54° C (129.2° F): This temperature is too high and poses a significant risk for burns or scalding. The recommended maximum water heater setting for safety is 49° C (120° F), especially in homes with children or older adults.
C. The batteries in the smoke alarms are changed annually: Changing smoke alarm batteries once a year aligns with fire safety recommendations. Functioning smoke alarms are a critical part of home safety and fire prevention.
D. A single light fixture hangs along the sidewalk to the house: One light may not provide adequate visibility, especially in poor weather or at night. Multiple, evenly spaced light sources are more effective for preventing trips or falls along walkways.
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