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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Vancomycin is not typically associated with hepatotoxicity.
B. Ototoxicity, which can manifest as hearing loss or tinnitus, is a potential adverse reaction of vancomycin therapy, especially with prolonged or high-dose therapy. Monitoring for signs of hearing impairment is essential.
C. Hypercalcemia is not a common adverse reaction associated with vancomycin therapy.
D. Hypertension is not a common adverse reaction associated with vancomycin therapy.
Correct Answer is C
Explanation
A. Failure to engraft is characterized by the absence of new bone marrow cell growth, leading to persistent low blood counts. It does not typically present with skin peeling or desquamation.
B. Veno-occlusive disease primarily affects the liver and presents with symptoms such as weight gain, hepatomegaly, and jaundice. Skin desquamation is not a common manifestation of this complication.
C. Graft-versus-host disease commonly affects the skin, liver, and gastrointestinal tract, with early signs including rash and desquamation of the hands and feet. This finding is a hallmark indication of this complication following a bone marrow transplant.
D. Pancytopenia involves a reduction in red blood cells, white blood cells, and platelets, leading to fatigue, infection risk, and bleeding. It does not typically cause skin peeling.
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