Level: Foundational
Difficulty: Easy
Subtopic: Pregnancy complications
NCLEX: A 29-year-old client in labor and delivery is being evaluated for preeclampsia symptoms. Assessment data include…
Maternal-newborn nursing Health Promotion and Maintenance Reduction of Risk Potential
Case Study
A 29-year-old client in labor and delivery is being evaluated for preeclampsia symptoms. Assessment data include decreased fetal movement compared with the client's usual pattern. Which action should the nurse take first?
Question
A. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
B. Offer a warm blanket and reschedule assessment until after lunch.
C. Complete all remaining scheduled tasks before reassessing the client.
D. Wait for the provider's routine visit before acting on abnormal findings.
B. Offer a warm blanket and reschedule assessment until after lunch.
C. Complete all remaining scheduled tasks before reassessing the client.
D. Wait for the provider's routine visit before acting on abnormal findings.
Rationale
Correct answer: A. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
Rationale: NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.