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 C

Explanation

A. Have the client hold their breath during the examination. This is not recommended, as slow, deep breathing helps the client relax and reduces discomfort.
B. Ensure that the client's bladder is full. The bladder should be emptied before the exam to enhance comfort and allow better access for the provider.
C. Instruct the client to bear down when the speculum is inserted. This helps relax the pelvic muscles and makes insertion easier, reducing discomfort.
D. Place the client in modified Sims' position. The lithotomy position is the correct positioning for a pelvic examination, not modified Sims'.

A. Establish a new routine for the child to follow while in the facility. B. Use medical terminology when discussing procedures with the child. C. Encourage the child to play with toys such as a pounding board. D. Perform the morning assessments when the parent is not in the room.

Correct Answer is C

Explanation

A. Establish a new routine for the child to follow while in the facility. This is incorrect because preschoolers find comfort in familiar routines. Maintaining their usual routines as much as possible helps reduce anxiety.
B. Use medical terminology when discussing procedures with the child. This is incorrect because preschoolers have a limited understanding of medical terms. Using simple, age-appropriate language helps them better comprehend what is happening.
C. Encourage the child to play with toys such as a pounding board. This is correct because preschoolers benefit from play to express emotions and relieve stress. Toys like a pounding board allow them to release frustration in a safe and developmentally appropriate way.
D. Perform the morning assessments when the parent is not in the room. This is incorrect because having a parent present provides comfort and security, which can help the child remain calm during assessments.

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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

A nurse is preparing a client for a pelvic examination. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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