A nurse on a labor and delivery unit is assessing four newly admitted clients. Which of the following clients should the nurse see first?
A client who is at 38 weeks of gestation and reports irregular uterine contractions
A client who is at 39 weeks of gestation and is scheduled for a weekly nonstress test (NST)
A client who is at 40 weeks of gestation and is scheduled for an induction of labor
A client who is at 36 weeks of gestation and reports decreased fetal movement for 2 days
The Correct Answer is D
A. Irregular uterine contractions at 38 weeks of gestation may not be a concern unless they become regular and more intense.
B. A client scheduled for a nonstress test (NST) at 39 weeks of gestation can typically wait until after attending to more urgent matters.
C. A client scheduled for an induction of labor at 40 weeks of gestation is not necessarily a priority unless there are urgent concerns.
D. Decreased fetal movement, especially for 2 days at 36 weeks of gestation, requires immediate assessment to ensure fetal well-being.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. This response may come across as confrontational and could potentially shut down further communication. It's important to offer support and empathy rather than immediately probing with questions.
B. While saying, "You can trust me and tell me what you are thinking," may foster trust, it is too vague and does not focus on assessing the client’s level of suicidal ideation or intent. Effective responses should prioritize safety by exploring specific details about the client’s thoughts.
C. "I need to know what you mean by misery" focuses on understanding the client’s emotional state but does not address the immediate concern of suicidal thoughts. While exploring the client’s feelings is important, it is secondary to assessing imminent risk.
D. Asking, "Do you have a plan to end your life?" is appropriate because it directly assesses the client’s risk for suicide. Determining whether the client has a specific plan, the means to carry it out, and intent to act is essential for evaluating the severity of the situation and implementing safety measures.
Correct Answer is B
Explanation
A. This is not an appropriate action for a client experiencing acute mania. A flexible activity schedule may exacerbate symptoms by allowing too much freedom, leading to overstimulation and a lack of focus. Structured activities with clear boundaries are more effective for managing manic behaviors.
B. Providing high-calorie nutritional supplements is essential for clients in acute mania because they often exhibit hyperactivity and may neglect to eat or drink adequately. These supplements help maintain nutritional balance and prevent weight loss or dehydration during this period of heightened energy and poor self-care.
C. Allowing the client to eat meals alone in her room is not appropriate. Clients with acute mania benefit from supervised, structured environments to ensure they are eating and engaging in necessary self-care. Isolation may also increase feelings of disorganization or exacerbate symptoms.
D. Allowing the client to choose her clothes independently is not recommended during acute mania, as poor judgment and impulsivity may lead to inappropriate or excessive clothing choices. Providing simple, preselected clothing options helps reduce decision-making stress and ensures appropriate attire.
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