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 12 weeks of gestation and is experiencing nausea and vomiting
A client who is at 34 weeks of gestation and is experiencing epigastric pain and headache
A client who is at 38 weeks of gestation and is experiencing painful urination
A client who is at 39 weeks of gestation and is experiencing cramping and spotting
The Correct Answer is B
Among the given options, the client who is at 34 weeks of gestation and experiencing epigastric pain and headache should be assessed first. Epigastric pain and headache can be signs of preeclampsia, a serious condition characterized by high blood pressure and organ dysfunction during pregnancy. Preeclampsia requires immediate attention as it can lead to complications for both the mother and the fetus.
Option a) A client at 12 weeks of gestation experiencing nausea and vomiting may be experiencing normal symptoms of early pregnancy. While it is important to assess the client's well-being, it is not an immediate priority compared to the potential signs of preeclampsia in option b.
Option c) A client at 38 weeks of gestation experiencing painful urination may indicate a urinary tract infection (UTI). While a UTI should be addressed, it does not pose the same level of immediate risk as the potential signs of preeclampsia in option b.
Option d) A client at 39 weeks of gestation experiencing cramping and spotting may be in early labor or have other signs of impending labor. While it is important to assess this client's condition, it is not an immediate priority compared to the potential signs of preeclampsia in option b.
Therefore, the nurse should assess the client who is at 34 weeks of gestation and experiencing epigastric pain and headache as the first priority. Prompt evaluation and management of preeclampsia symptoms are crucial to prevent complications and ensure the well-being of both the mother and the fetus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A nonstress test (NST) is a common procedure used to assess the well-being of the fetus. During an NST, the fetal heart rate is monitored for a period of time to evaluate its response to fetal movement. In a normal NST, the fetal heart rate should show accelerations (temporary increases in heart rate) with fetal movement. Lack of accelerations can indicate fetal compromise or a non-reactive test.
In the given scenario, the absence of accelerations for 20 minutes indicates a non-reactive NST. In such cases, further interventions may be required to stimulate the fetus and provoke a response. Vibroacoustic stimulation is a non-invasive method that involves using sound or vibration to stimulate the fetus and elicit a fetal heart rate acceleration. It can be performed by placing a device on the mother's abdomen and delivering a brief sound or vibration near the fetal head.
Option a) Placing the client in the Trendelenburg position is not appropriate in this situation. The Trendelenburg position involves placing the client's head lower than the feet, and it is not indicated for a non-reactive NST.
Option b) Conducting a vaginal exam is not necessary in this scenario. The non-reactive NST indicates a lack of fetal heart rate accelerations, and a vaginal exam would not provide additional information or help in this situation.
Option c) Collecting a specimen for an indirect Coombs test is unrelated to the non-reactive NST. An indirect Coombs test is used to detect antibodies in the mother's blood that could potentially cause hemolytic disease of the newborn. It is not indicated as a response to a non-reactive NST.
Correct Answer is C
Explanation
This is the method that the nurse should use to elicit the Moro reflex. The Moro reflex, or startle reflex, is an involuntary motor response that infants develop shortly after birth. It is a response to a sudden loss of support or extremely sudden stimulation¹. A loud noise above the newborn can trigger the Moro reflex by startling the infant. The Moro reflex involves three distinct components: spreading out the arms (abduction), pulling the arms in (adduction), and crying (usually)².
The other options are not correct because they do not elicit the Moro reflex.
a) Turn the newborn's head to one side.
This does not elicit the Moro reflex, but rather the tonic neck reflex. The tonic neck reflex occurs when the infant turns their head to one side and assumes a "fencing" posture, with the arm and leg on the same side extended and the opposite arm and leg flexed.
b) Touch the newborn's cheek with a finger.
This does not elicit the Moro reflex, but rather the rooting reflex. The rooting reflex occurs when the infant turns their head and opens their mouth in response to a touch on their cheek or mouth. This reflex helps the infant locate and latch onto a nipple for feeding³.
d) Tap the newborn's forehead with a finger.
This does not elicit the Moro reflex, but rather the glabellar reflex. The glabellar reflex occurs when the infant blinks in response to a tap on their forehead or bridge of their nose. This reflex helps protect the eyes from injury³.
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