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 C
Explanation
GTPAL calculation:
Step 1 is: Determine Gravida (G) = 4 pregnancies (1 elective abortion, 1 twin birth, 1 spontaneous abortion, 1 current pregnancy) = G4.
Step 2 is: Determine Term (T) births = 0 (no pregnancies reached 37 weeks).
Step 3 is: Determine Preterm (P) births = 1 (twin birth at 36 weeks) = P1.
Step 4 is: Determine Abortion (A) = 2 (1 elective abortion at 9 weeks, 1 spontaneous abortion at 15 weeks) = A2.
Step 5 is: Determine Living (L) children = 2 (twins) = L2.
The GTPAL status is: G4 T0 P1 A2 L2.
Correct Answer is C
Explanation
Choice A rationale
While it’s important for the nurse to provide reassurance and support during the exam, this statement alone doesn’t address the client’s specific concerns or provide any useful information.
Choice B rationale
Telling the client to relax doesn’t address her concerns or provide any useful information. It’s normal to feel nervous before a pelvic exam, especially if it’s the first one.
Choice C rationale
Asking the client what part of the exam makes her most nervous allows the nurse to provide specific information and reassurance, which can help alleviate the client’s anxiety.
Choice D rationale
While a pelvic exam is often part of the process when starting oral contraceptives, it’s not always required. The need for a pelvic exam can depend on the client’s age, sexual history, and other factors.
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