A nurse is caring for four children in an emergency department.
Which of the following clients should the nurse assess first?

A child who has mononucleosis and reports severe fatigue.

A child who has Wilms' tumor and an abdominal mass.

A child who has acute epiglottitis and is drooling.

A child who has a urinary tract infection and bright red blood in her urine.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

A child who has mononucleosis and reports severe fatigue requires medical attention, but this condition does not pose an immediate life-threatening risk compared to acute epiglottitis. Mononucleosis is a viral infection that can cause fatigue, sore throat, and swollen lymph nodes. While the child should be assessed, the priority is given to the child with acute epiglottitis due to the potential for airway obstruction and respiratory distress.

Choice B rationale:

A child who has Wilms' tumor and an abdominal mass also needs urgent medical evaluation. Wilms' tumor is a rare kidney cancer that primarily affects children. While it requires prompt attention, acute epiglottitis poses a more immediate threat to the airway and breathing.

Choice C rationale:

A child with acute epiglottitis and drooling requires immediate assessment and intervention. Acute epiglottitis is a potentially life-threatening infection that can cause severe swelling of the epiglottis, leading to airway obstruction. The child may have difficulty breathing and may present with the classic drooling sign due to the inability to swallow saliva. Prompt medical intervention, including airway management and appropriate antibiotics, is essential in this situation.

Choice D rationale:

A child with a urinary tract infection and bright red blood in her urine requires medical evaluation, but this condition is not as urgent as acute epiglottitis. Hematuria (blood in the urine) can have various causes, including urinary tract infections or kidney stones. While the child should receive medical attention, it does not take precedence over the immediate threat posed by acute epiglottitis, which requires urgent intervention to maintain the airway.

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Correct Answer is ["A","B","C","D"]

Explanation

- A: Correct. Firmly massaging the uterine fundus helps to contract the uterus and reduce bleeding.

- B: Correct. Providing emotional support helps to calm the client and reduce anxiety, which can worsen bleeding.

- C: Correct. Administering oxygen helps to improve tissue perfusion and oxygenation, which can be compromised by blood loss. Weighing the perineal pads helps to quantify the amount of blood loss and monitor for hemorrhage.

- D: Correct. Inserting an indwelling urinary catheter helps to empty the bladder and allow the uterus to descend and contract more effectively. Administering methylergonovine helps to stimulate uterine contractions and control bleeding.

- E: Incorrect. Administering terbutaline is contraindicated in this situation, as it relaxes the uterine smooth muscle and increases bleeding.

A. Uterine rupture. B. Placental abruption. C. Placenta previa. D. Amniotic fluid embolus.

Correct Answer is B

Explanation

Choice A rationale:

Uterine rupture typically presents with intense, constant abdominal pain and signs of shock. However, the absence of visible bleeding in the abdominal cavity makes this choice less likely in this case.

Choice B rationale:

Placental abruption involves the premature separation of the placenta from the uterine wall before delivery. The sudden, severe abdominal pain, moderate vaginal bleeding, persistent uterine contractions, and signs of hypovolemic shock (low blood pressure, rigid abdomen) are indicative of placental abruption. This condition requires immediate medical intervention due to the risk of fetal and maternal compromise.

Choice C rationale:

Placenta previa occurs when the placenta partially or completely covers the cervical opening. It typically presents with painless, bright red vaginal bleeding. The severe abdominal pain described in the scenario is inconsistent with placenta previa.

Choice D rationale:

Amniotic fluid embolus is a rare and life-threatening condition in which amniotic fluid enters the maternal bloodstream, causing an allergic reaction. It can lead to sudden cardiovascular collapse. Although it can cause respiratory distress and hypotension, it does not usually present with severe abdominal pain or uterine contractions.

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A nurse is caring for four children in an emergency department.Which of the following clients should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","D"]

Explanation

Correct Answer is B

Explanation

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A nurse is caring for four children in an emergency department.
Which of the following clients should the nurse assess first?