A nurse in the emergency department is caring for a group of clients.
Which of the following clients should the nurse plan to see first?
A client who is at 6 weeks of gestation with severe abdominal pain, no bleeding, a blood pressure of 86/58 mm Hg and a pulse of 132/min.
A client who has an ectopic pregnancy, a blood pressure of 128/84 mm Hg a pulse of 88/min, and is crying.
A client who is at 9 weeks of gestation, took one dose of methotrexate and is now reporting moderate pain and dizziness, has a blood pressure of 116/80 mm Hg and a pulse of 86/min.
A client who is at 8 weeks of gestation with moderate vaginal bleeding, has minimal abdominal pain, a blood pressure of 118/72 mm Hg and a pulse of 96/min.
The Correct Answer is A
Choice A rationale
The client at 6 weeks gestation exhibiting severe abdominal pain, hypotension (86/58 mm Hg), and tachycardia (132/min) suggests a potential ruptured ectopic pregnancy or other acute abdominal emergency requiring immediate intervention. Hypotension indicates inadequate tissue perfusion, and tachycardia is a compensatory mechanism to maintain cardiac output. Severe pain further indicates an acute process that necessitates prompt assessment and treatment to prevent further hemodynamic instability and potential life-threatening complications.
Choice B rationale
While a client with an ectopic pregnancy requires monitoring and care, the vital signs reported (blood pressure 128/84 mm Hg, pulse 88/min) are within normal limits. Normal blood pressure ranges are typically systolic 90-120 mm Hg and diastolic 60-80 mm Hg, and a normal pulse rate is generally 60-100 beats per minute. Although emotional distress from the diagnosis is important, the physiological parameters do not indicate an immediate critical threat compared to the client in Choice A.
Choice C rationale
A client at 9 weeks gestation who received methotrexate for an ectopic pregnancy and reports moderate pain and dizziness with stable vital signs (blood pressure 116/80 mm Hg, pulse 86/min) requires assessment for expected side effects of the medication or signs of treatment failure. Methotrexate can cause abdominal pain as it works to dissolve the pregnancy. While monitoring is necessary, the stable vital signs do not suggest an immediate life-threatening emergency compared to the client in Choice A.
Choice D rationale
A client at 8 weeks gestation with moderate vaginal bleeding, minimal abdominal pain, and stable vital signs (blood pressure 118/72 mm Hg, pulse 96/min) may be experiencing a threatened or inevitable miscarriage. While vaginal bleeding in early pregnancy warrants investigation and monitoring, the stable vital signs and minimal pain do not indicate an immediate critical emergency requiring prioritization over the client in Choice A who presents with signs of hemodynamic instability. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","F","G"]
Explanation
Choice B rationale
Prostaglandin administration, either vaginally or orally, helps to ripen the cervix by increasing collagenase activity and water content, leading to cervical softening, thinning (effacement), and dilation, which are necessary for labor to begin.
Choice F rationale
Amniotomy, or artificial rupture of membranes (AROM), involves the deliberate rupture of the amniotic sac. This can stimulate labor by releasing prostaglandins, increasing uterine contractility, and allowing the presenting part of the fetus to descend further into the pelvis, putting pressure on the cervix.
Choice G rationale
Oxytocin is a synthetic hormone that mimics the action of endogenous oxytocin, stimulating uterine contractions. It is commonly administered intravenously to initiate or augment labor once cervical ripening has occurred or the cervix is favorable.
Choice A rationale
Epidural anesthesia is a method of pain relief during labor, not a method for inducing labor. It provides regional analgesia by blocking nerve impulses in the lower body.
Choice C rationale
Bed rest is generally not recommended for labor induction and can even be counterproductive. Ambulation and positional changes can help to encourage fetal descent and uterine activity.
Choice D rationale
Vitamin supplementation is important for overall maternal and fetal health during pregnancy but does not directly stimulate uterine contractions or cervical changes necessary for labor induction.
Choice E rationale
Fetal ultrasound is used to assess fetal well-being, presentation, and amniotic fluid volume but does not initiate the process of labor induction. .
Correct Answer is D
Explanation
Choice A rationale
Preparing to administer a prescribed oxytocic preparation is a possible intervention for postpartum hemorrhage, but the immediate first step should be to assess the uterus, the most common source of early postpartum bleeding.
Choice B rationale
Assessing the client's blood pressure is important in evaluating the extent of blood loss, but it is not the initial action to take. Addressing the likely cause of the bleeding should precede further assessment of vital signs.
Choice C rationale
Assessing the bladder for distention is important as a full bladder can displace the uterus and interfere with its contraction, potentially contributing to bleeding. However, directly addressing the uterine tone is the immediate first step.
Choice D rationale
Massaging the client's fundus is the priority action because uterine atony, a soft and non-contracted uterus, is the most frequent cause of early postpartum hemorrhage. Stimulating the uterus to contract by massage helps to compress the blood vessels at the placental site and decrease bleeding. .
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