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 C
Explanation
Rationale:
A. Penicillin: Saw palmetto does not interfere with antibiotic action or metabolism. No significant pharmacodynamic or pharmacokinetic interaction exists between penicillin and saw palmetto.
B. Zolpidem: While both may cause some central nervous system effects, there is no established adverse interaction between zolpidem and saw palmetto. Co-administration is generally not contraindicated.
C. Clopidogrel: Saw palmetto has antiplatelet properties and can potentiate the effects of clopidogrel, increasing the risk of bleeding. Clients taking both may face elevated risk of gastrointestinal or intracranial hemorrhage.
D. Ipratropium: Ipratropium is an anticholinergic agent used primarily for respiratory conditions. It does not have a known interaction with saw palmetto, and their pharmacologic mechanisms do not overlap.
Correct Answer is ["A","B","C","D","E","F"]
Explanation
Rationale:
A. Blood pressure: Orthostatic hypotension is evident from the drop in systolic and diastolic pressure when standing, indicating fluid and electrolyte imbalance. This may reflect volume depletion due to purging and requires monitoring to prevent fainting or falls.
B. Syncope: The client reports repeated fainting episodes, a red flag when paired with orthostatic hypotension and electrolyte disturbances. This suggests unstable cardiovascular status and raises the risk of injury or sudden cardiac events.
C. ECG: Sinus tachycardia with premature ventricular contractions indicates cardiac irritability likely due to electrolyte imbalance, especially hypokalemia. Continuous cardiac monitoring and correction of abnormalities are needed.
D. Albumin: An albumin level of 2.6 g/dL indicates significant malnutrition and protein deficiency, compromising immune function and wound healing. This also suggests a chronic issue requiring dietetic intervention and nutritional rehabilitation.
E. Potassium: Potassium at 3.0 mEq/L is dangerously low and a known contributor to cardiac arrhythmias and muscle weakness. Replenishment and close monitoring are critical to avoid complications such as cardiac arrest.
F. Sodium: Although sodium is only slightly low at 134 mEq/L, in the context of purging and poor intake, this could indicate dilutional hyponatremia. It increases seizure risk and needs assessment of fluid status and intake behaviors.
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