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
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).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Answer is: a. Urine protein of 3+
Explanation:
- Urine protein of 3+ indicates severe proteinuria, which is a sign of preeclampsia and can lead to kidney damage. The nurse should report this finding to the provider as it may require medication or delivery intervention.
- Deep tendon reflexes of 2+ are normal and do not indicate preeclampsia. The nurse should monitor the client for hyperreflexia, which is a sign of increased neuromuscular irritability and can precede seizures.
- Hemoglobin 13 g/dL is within the normal range for a pregnant client and does not indicate preeclampsia. The nurse should monitor the client for anemia, which can cause maternal and fetal complications.
- Blood glucose 110 mg/dL is slightly elevated but not diagnostic of gestational diabetes, which is a different condition from preeclampsia. The nurse should advise the client to follow a balanced diet and exercise regimen and to undergo a glucose tolerance test at 24 to 28 weeks of gestation.
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Correct Answer is D
Explanation
The correct answer is choice D: Place the client in a lateral position. Late decelerations of the fetal heart rate on the monitor tracing can indicate fetal distress, which is a potential complication of oxytocin induction of labor. Placing the client in a lateral position can improve uteroplacental blood flow and may improve fetal oxygenation.
Choice A, administering misoprostol 25 mcg vaginally, can increase uterine contractions and may further compromise fetal oxygenation. Choice B, decreasing maintenance IV solution infusion rate, and choice C, administering oxygen via face mask at 2 L/min, are not effective interventions for late decelerations of the fetal heart rate.
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