A nurse in an antepartum clinic is caring for four clients. Which of the following clients should the nurse assess first?

A client who is at 34 weeks of getation and reports double vision

A client who is at 38 weeks of gestation and reports leg cramps

A client who is at 8 weeks of gestation and reports excessive salivation

A client who is at 24 weeks of gestation and reports periodic finger numbness

Answer and Explanation

The Correct Answer is A

A. Double vision at 34 weeks of gestation is a potential sign of preeclampsia, which can lead to severe complications such as seizures (eclampsia), stroke, or organ damage. This client requires immediate assessment.
B. Leg cramps are common in late pregnancy due to pressure on nerves and changes in circulation. This is not an urgent concern.
C. Excessive salivation (ptyalism) is benign and can occur in early pregnancy due to hormonal changes. It does not require immediate assessment.
D. Periodic finger numbness is often due to carpal tunnel syndrome, a common non-urgent condition in pregnancy caused by fluid retention.

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Correct Answer is B

Explanation

A. Schedule the client for an MRI after the procedure. This is incorrect because an MRI is not required following a thoracentesis. Instead, a chest X-ray may be ordered to assess for complications such as a pneumothorax.
B. Place the client leaning forward over the overbed table. This is correct because this position allows for optimal lung expansion and easier access to the pleural space for fluid removal.
C. Encourage the client to take deep breaths during the procedure. This is incorrect because the client should remain still and avoid deep breathing or coughing to prevent lung injury.
D. Ensure the client has been NPO for 6 hr. This is incorrect because NPO status is not required for a thoracentesis, as it is not a gastrointestinal or sedation-based procedure.

A. Apply restraints if the client is agitated. B. Ambulate the client. C. Position the client on their side. D. Raise all of the side rails on the client's bed.

Correct Answer is C

Explanation

A. Apply restraints if the client is agitated. Restraints are not necessary and may increase distress. Post-seizure agitation should be managed with reassurance and monitoring.
B. Ambulate the client. This is unsafe because the client may be disoriented or weak, increasing the risk of falls. Rest and recovery should be prioritized.
C. Position the client on their side. This helps maintain an open airway, prevents aspiration, and facilitates secretion drainage, making it the priority intervention.
D. Raise all of the side rails on the client's bed. Raising all four side rails is considered a restraint. A safer environment should be maintained without unnecessary restriction.

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A nurse in an antepartum clinic is caring for four clients. Which of the following clients should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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