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 ["A","B","C","E"]
Explanation
Choice A rationale
Anomalies in fetal chromosomes can be identified through amniocentesis. This test involves the extraction of a small amount of amniotic fluid, which contains fetal tissues. The chromosomes of the fetus can be examined for abnormalities.
Choice B rationale
Cephalopelvic disproportion refers to a condition where the mother’s pelvis is too small to allow the baby to pass through the birth canal. This condition cannot be identified through amniocentesis. Amniocentesis is a diagnostic procedure that examines the amniotic fluid (not the maternal pelvis or the size of the fetus) to detect chromosomal abnormalities and certain genetic disorders.
Choice C rationale
Fetal gender can be determined through amniocentesis. The test can identify the presence of Y chromosomes, which would indicate a male fetus.
Choice D rationale
Rh incompatibility is a condition that occurs when a mother is Rh-negative and the baby is Rh-positive. This condition cannot be identified through amniocentesis. Instead, it is typically identified through blood tests of the mother and father.
Choice E rationale
Neural tube defects, such as spina bifida and anencephaly, can be identified through amniocentesis. The test can detect high levels of alpha-fetoprotein, which is often present when a fetus has a neural tube defect.
Correct Answer is D
Explanation
Choice A rationale
The symptoms described by the client do not typically align with conditions that would lead to Anticipate A. Anticipate A might be expected for a different set of symptoms or conditions.
Choice B rationale
The symptoms described by the client do not typically align with conditions that would lead to Anticipate B. Anticipate B might be expected for a different set of symptoms or conditions.
Choice C rationale
The symptoms described by the client do not typically align with conditions that would lead to Anticipate C. Anticipate C might be expected for a different set of symptoms or conditions.
Choice D rationale
The client’s symptoms of recent painful sores on the perineum, muscle aches, and chills, along with current discomfort when sitting and mild vaginal itching, could suggest a herpes simplex virus infection or another type of infection. Anticipate D might be an antiviral medication or other treatment to address the suspected condition.
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