A nurse on an antepartum unit is receiving change-of-shift report for four clients. Which of the following clients should the nurse assess first?

A client who is at 38 weeks of gestation and is experiencing painful urination

A client who is at 34 weeks of gestation and is experiencing epigastric pain and headache

A client who is at 12 weeks of gestation and is experiencing nausea and vomiting

A client who is at 39 weeks of gestation and is experiencing cramping and spotting

Answer and Explanation

The Correct Answer is B

The client who is at 34 weeks of gestation and is experiencing epigastric pain and headache should be assessed first. These symptoms may indicate preeclampsia, which is a serious pregnancy complication characterized by high blood pressure and organ damage. The nurse should monitor the client's blood pressure and assess for signs of organ damage, such as proteinuria, visual disturbances, and epigastric or right upper quadrant pain. The other clients may also require assessment and intervention, but their symptoms are less urgent and may indicate less serious conditions, such as a urinary tract infection (painful urination), early pregnancy symptoms (nausea and vomiting), or early labor (cramping and spotting).

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Correct Answer is C

Explanation

The correct answer is choice C, Ensure the newborn's eyes are closed beneath the shield. Phototherapy is a treatment used to reduce high bilirubin levels in newborns. It involves exposing the newborn's skin to special lights, which helps to break down the excess bilirubin in the blood. It is important to ensure that the newborn's eyes are closed beneath the shield to prevent damage to the eyes from the bright lights. Giving the newborn 1 oz of glucose water every 4 hr, applying lotion to the newborn's skin every 8 hr, and dressing the newborn in a thin layer of clothing during therapy are not indicated interventions during phototherapy.

A. Overlapping of the cranial bones B. Small, distended white sebaceous glands on the face C. Bluish discoloration of the hands and feet D. Forward and lateral positioning of the ears

Correct Answer is D

Explanation

A.Cranial bone overlap (molding) is common after vaginal delivery due to compression during birth. It typically resolves within a few days and does not require urgent intervention.

B.These are called milia, which are harmless and expected in newborns. They resolve spontaneously without treatment.

C.This is known as acrocyanosis, a normal finding in newborns during the first 24–48 hours of life due to immature circulation. It is not a cause for concern unless central cyanosis is present (e.g., lips or mucous membranes are blue).

D.Abnormal positioning of the ears (e.g., low-set or forward and lateral) can be a sign of congenital anomalies, particularly renal abnormalities or chromosomal syndromes such as Trisomy 21 (Down syndrome) or Trisomy 18. Because these may indicate serious underlying systemic conditions, the nurse must report this finding promptly to initiate further evaluation and possibly diagnostic testing (e.g., renal ultrasound or genetic consultation).

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A nurse on an antepartum unit is receiving change-of-shift report for four clients. Which of the following clients should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a newborn who is scheduled to start phototherapy using a lamp. Which of the following actions should the nurse include in the plan?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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