A nurse is triaging clients in an urgent care clinic. Which of the following clients should the nurse have the provider care for immediately?

A toddler who has a laceration on his forehead and is crying

An adolescent female client who is belligerent and has slurred speech

A young adult with a painful sunburn of his face and arms

A middle adult male who is diaphoretic and reports epigastric pain

Answer and Explanation

The Correct Answer is D

A. A laceration on the forehead of a toddler, while needing attention, is not as urgent as symptoms suggestive of a myocardial infarction.
B. Belligerence and slurred speech in an adolescent could indicate substance use or neurological issues, but it is less immediately life-threatening than symptoms of a myocardial infarction.
C. While painful sunburn can be uncomfortable, it is not as critical as symptoms indicative of a potential heart attack.
D. Diaphoresis and epigastric pain can be symptoms of a myocardial infarction (heart attack), which is a potentially life-threatening condition requiring immediate medical attention.

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Correct Answer is C

Explanation

A. While rupture of the membranes can be an indication of labor, it is not a definitive sign of true labor on its own. Membranes can rupture before labor begins, or labor can start without membrane rupture.
B. The pattern of contractions can be variable in false labor and does not alone distinguish between true and false labor. True labor contractions typically become progressively stronger, more regular, and closer together.
C. Changes in the cervix, such as dilation and effacement, are clear indicators of true labor. In true labor, the cervix undergoes progressive changes, while in false labor, these changes do not occur.
D. The station of the presenting part refers to the position of the fetus in relation to the ischial spines and is not a standalone indicator of true labor. Cervical changes are a more definitive sign.

A. "This will happen by the end of the first trimester of pregnancy." B. "This will occur between the fourth and fifth months of pregnancy." C. "This will occur during the last trimester of pregnancy." D. "This will happen once the uterus begins to rise out of the pelvis."

Correct Answer is B

Explanation

A. Quickening, or the first movements of the fetus felt by the mother, typically occurs between 16 to 20 weeks of gestation, which is well after the first trimester.
B. Quickening generally occurs between the fourth and fifth months of pregnancy (16 to 20 weeks). By this time, the fetal movements are usually felt by the mother.
C. Quickening does not occur during the last trimester but rather in the middle of pregnancy.
D. The uterus rising out of the pelvis typically occurs earlier in the second trimester and is not directly related to the onset of quickening.

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A nurse is triaging clients in an urgent care clinic. Which of the following clients should the nurse have the provider care for immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor?

Correct Answer is C

Explanation

A nurse is caring for a client who is at 6 weeks of gestation with her first pregnancy and asks the nurse when she can expect to experience quickening. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

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A nurse is triaging clients in an urgent care clinic. Which of the following clients should the nurse have the provider care for immediately?

A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding?

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