A nurse at an antepartum clinic is caring for four clients. Which of the following clients should the nurse assess first?
A client who is at 36 weeks of gestation and reports back pain following intercourse
A client who is at 8 weeks of gestation and reports severe vomiting
A client who is at 10 weeks of gestation and reports frequent urination
A client who is at 24 weeks of gestation and reports periodic tingling of the fingers
The Correct Answer is B
Rationale:
A. Back pain following intercourse at 36 weeks of gestation may be common and is not typically indicative of an urgent issue.
B. Severe vomiting in early pregnancy could indicate hyperemesis gravidarum, which may require immediate assessment and intervention to prevent dehydration and electrolyte imbalances.
C. Frequent urination at 10 weeks of gestation is common due to hormonal changes and increased pressure on the bladder from the growing uterus, but it does not typically require immediate assessment unless accompanied by other concerning symptoms.
D. Periodic tingling of the fingers at 24 weeks of gestation could be due to carpal tunnel syndrome, which is common in pregnancy but does not usually require urgent assessment unless severe or accompanied by other symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C,A,B,D,E
Explanation
C. Instruct the client to empty their bladder.
A. Position the client supine with knees flexed and place a small rolled towel under one of their hips.
B. Palpate the fetal part positioned in the fundus.
D. Palpate the fetal parts along both sides of the uterus.
E. Palpate the fetal part positioned above the symphysis pubis.
Correct Answer is D
Explanation
A: Administering an IV bolus of lactated Ringer's is typically used to correct electrolyte imbalances or as a volume expander in the case of blood loss. In peripartum cardiomyopathy, fluid overload should be avoided as it can exacerbate heart failure symptoms.
B: Misoprostol is used to prevent or treat postpartum hemorrhage, but it is not directly related to the management of peripartum cardiomyopathy.
C. Assess blood pressure twice daily:
While monitoring blood pressure is important for overall cardiovascular management, assessing it only twice daily is insufficient for a client with peripartum cardiomyopathy. This condition requires frequent and comprehensive monitoring of vital signs, fluid balance, and cardiac function to prevent complications.
D. Restrict daily oral fluid intake:
Restricting fluid intake is a key intervention in managing peripartum cardiomyopathy because it helps to prevent fluid overload, which could exacerbate heart failure. Clients with this condition often experience reduced cardiac output, and limiting fluids can reduce the strain on the heart and improve overall management of symptoms
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