NCLEX Practice Test

A pregnant client at 38 weeks gestation is admitted to the labor and delivery unit reporting contractions, severe abdominal pain, and dark vaginal bleeding. What is the nurse's priority action?

1. Initiate large-bore (18-gauge) peripheral IV line

2. Notify operating room staff of emergency cesarean birth

3. Palpate abdomen and apply fetal heart rate monitor

4. Perform vaginal examination to assess cervical dilation

The correct answer is: Initiate large-bore (18-gauge) peripheral IV line

In this scenario, the pregnant client presents with concerning symptoms of contractions, severe abdominal pain, and dark vaginal bleeding. At 38 weeks gestation, the client is likely in active labor and in need of immediate medical attention. In order to address the client's symptoms and prevent further complications, the nurse's priority action should be to initiate a large-bore peripheral IV line to provide fluid and medication support as needed. Option B is incorrect because while cesarean birth may be necessary, it is not the immediate priority in this situation. Option C, palpating the abdomen and applying a fetal heart rate monitor, is important but can be done simultaneously while initiating the IV line. Option D, performing a vaginal examination, may be necessary later on but is not the immediate priority. Thus, the correct answer is A.