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
Choice C rationale
Phenylketonuria (PKU) is a metabolic disorder that results in decreased metabolism of the amino acid phenylalanine. High levels of phenylalanine can lead to intellectual disability and other serious health problems. Foods high in protein, such as peanut butter, contain high levels of phenylalanine and should be avoided by individuals with PKU34.
Correct Answer is A
Explanation
Choice A rationale
The nurse should include in the teaching that a client who is 23 weeks pregnant can receive an influenza vaccination during pregnancy. This is because the influenza vaccine is safe and recommended for pregnant women to protect both the mother and the baby from the flu.
Choice B rationale
The rubella vaccine is a live vaccine and is not recommended during pregnancy or while breastfeeding due to the potential risk to the baby. However, it can be given immediately after delivery if the woman is not immune.
Choice C rationale
The varicella vaccine is also a live vaccine and is not recommended during pregnancy. It should be given before pregnancy or immediately after delivery if the woman is not immune.
Choice D rationale
The Tdap (Tetanus, Diphtheria, Pertussis) vaccine is actually recommended during each pregnancy, regardless of the patient’s previous history of receiving the vaccine. The optimal timing for Tdap administration is between 27 and 36 weeks of gestation.
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