A nurse in an antepartum unit is triaging clients. Which of the following clients should the nurse see first?
A client who is at 38 weeks of gestation and reports a cough and fever.
A client who has missed a period and reports vaginal spotting.
A client who is at 14 weeks of gestation and reports nausea and vomiting.
A client who is at 28 weeks of gestation and reports painless vaginal bleeding.
The Correct Answer is D
A. A client at 38 weeks of gestation with a cough and fever may have an infection, which is concerning, but it is not immediately life-threatening. The nurse should assess this client soon, but it is not the highest priority.
B. A client who has missed a period and reports vaginal spotting could be experiencing an early pregnancy complication, such as a miscarriage or ectopic pregnancy. This situation requires attention, but it is not as urgent as painless vaginal bleeding in the third trimester.
C. A client at 14 weeks of gestation with nausea and vomiting is likely experiencing common pregnancy symptoms. While these symptoms can be uncomfortable and require management, they are not typically urgent.
D. A client at 28 weeks of gestation with painless vaginal bleeding could be experiencing placenta previa or another serious condition that poses an immediate risk to both the mother and the fetus. This situation requires urgent assessment and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A surge of energy: Some women experience a sudden burst of energy, often referred to as a "nesting" instinct, shortly before the onset of labor.
B. Urinary retention: Urinary frequency and urgency are more common before labor, not urinary retention.
C. Decreased vaginal discharge: Before labor, there might be an increase in vaginal discharge, often thick and pinkish, known as the "bloody show."
D. Weight gain of 0.5 to 1.5 kg: Weight gain is not typically associated with the onset of labor.
Correct Answer is B
Explanation
Choice A: This response is dismissive and does not validate the client's feelings. It may not address the client's concerns effectively.
Choice B: This response validates the client's feelings and reassures her that ambivalent feelings about pregnancy are common. It provides a supportive approach and normalizes her emotions.
Choice C: While counseling might be helpful for some clients, suggesting it immediately without further assessment of the client's needs may not be the most appropriate response at this stage.
Choice D: Encouraging the client to discuss her feelings with her mother may not be suitable, as the client might prefer professional support or may not have a positive relationship with her
mother. It is essential to avoid making assumptions about the client's support system and address her concerns empathetically.
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