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 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.
A client who has missed a period and reports vaginal spotting.
The Correct Answer is C
Choice A rationale
A cough and fever in a client at 38 weeks of gestation could indicate an infection, which should be addressed promptly. However, it is not as immediately life-threatening as painless vaginal bleeding at 28 weeks of gestation, which could indicate a serious complication such as placental abruption.
Choice B rationale
Nausea and vomiting at 14 weeks of gestation are common symptoms of early pregnancy and, while uncomfortable, are not usually a sign of a serious problem. This client should be seen, but not before a client with a potentially life-threatening condition like painless vaginal bleeding.
Choice C rationale
Painless vaginal bleeding at 28 weeks of gestation is a serious symptom that could indicate placental abruption, a condition where the placenta detaches from the uterus, which can be life-threatening for both the mother and the baby. This client should be seen first.
Choice D rationale
Vaginal spotting in a client who has missed a period could indicate early pregnancy or a number of other conditions. While this client should be seen to confirm the cause of the spotting, it is not as immediately urgent as painless vaginal bleeding at 28 weeks of gestation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While it might seem helpful to offer to tell the parents for the client, it’s important to respect the client’s autonomy and confidentiality. The nurse should support the client in making their own decisions about disclosure.
Choice B rationale
It’s not necessarily true that the parents will have to be told why the client is being admitted. Confidentiality is a key aspect of healthcare, especially when it comes to sensitive issues like sexually transmitted infections.
Choice C rationale
This response is empathetic and non-judgmental. It acknowledges the client’s feelings and opens up a conversation without forcing any action. This allows the client to feel heard and supported, which is crucial in a healthcare setting.
Choice D rationale
While this response might be well-intentioned, it assumes that the parents will understand and doesn’t acknowledge the client’s fear or concern. It’s important for the nurse to validate the client’s feelings and provide support.
Correct Answer is C
Explanation
Choice A rationale
Estrogen is a hormone that plays a crucial role in the menstrual cycle and pregnancy. However, it is not the primary hormone that triggers ovulation.
Choice B rationale
Progesterone is a hormone that prepares the uterus for pregnancy after ovulation. It does not trigger ovulation.
Choice C rationale
Luteinizing Hormone (LH) is the hormone that triggers ovulation. A surge in LH levels causes the mature follicle in the ovary to burst and release an egg.
Choice D rationale
Prostaglandins are hormone-like substances involved in pain and inflammation. They do not trigger ovulation.
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