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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice D rationale
Unilateral, cramp-like abdominal pain. This is a common symptom of an ectopic pregnancy. The pain usually starts on one side of the abdomen after the early stages of pregnancy and may be accompanied by spotting or vaginal bleeding.
Choice A rationale
Large amount of vaginal bleeding. While vaginal bleeding can occur in an ectopic pregnancy, it’s usually light to moderate, not large. Heavy vaginal bleeding is more commonly associated with miscarriage or other conditions.
Choice B rationale
Severe nausea and vomiting. While some women with an ectopic pregnancy may experience nausea and vomiting, these symptoms are common in early pregnancy and are not specific to ectopic pregnancy.
Choice C rationale
Uterine enlargement greater than expected for gestational age. This is not a typical symptom of an ectopic pregnancy. In fact, because the pregnancy is not in the uterus, the size of the uterus may be smaller than expected for the gestational age.
Correct Answer is D
Explanation
The correct answer is D. Slightly above the umbilicus. At about 20 weeks of pregnancy, the fundus of the uterus is usually at the level of the umbilicus. By 22 weeks, the fundus is typically slightly above the umbilicus.
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