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. Place the client in the lateral position. B. Elevate the client's legs. C. Increase the rate of maintenance IV infusion. D. Administer oxygen using a nonrebreather mask.

Correct Answer is A

Explanation

A. Late decelerations, where the fetal heart rate slows after the start of a contraction, indicate uteroplacental insufficiency. Placing the client in the lateral position helps improve blood flow to the placenta, which is the first intervention to address this condition.
B. Elevating the client’s legs is more appropriate for managing hypotension, not late decelerations. While it can help with blood flow, the priority intervention is repositioning to improve placental perfusion.
C. Increasing the rate of maintenance IV infusion may be necessary to enhance maternal blood volume and placental perfusion, but it is not the first action. Repositioning is the priority.
D. Administering oxygen can be beneficial in improving oxygen delivery to the fetus, but it is not the first action. The lateral position should be initiated before other interventions to optimize placental blood flow.

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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?

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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

Correct Answer is A

Explanation

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