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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Breast development is a normal part of fetal and neonatal growth. It occurs in stages, starting before birth and continuing during puberty and adulthood. Breast development is inﬂuenced by hormones, such as estrogen and progesterone, that are produced by the ovaries or the placenta¹².
Breast development in newborns can vary depending on the gestational age, sex, weight, and exposure to maternal hormones. Some newborns may have palpable breast tissue at birth, while others may develop it later in the first weeks of life. Some newborns may also secrete milk from their breasts, which is called witch's milk or neonatal galactorrhea. This is a harmless and temporary phenomenon that usually resolves within a few weeks without treatment³⁴.
The degree of breast development in newborns can be assessed by using a scoring system that ranges from 0 to 5, based on the size of the areola (the dark area around the nipple) and the presence of a bud (a small lump of glandular tissue under the areola). The scoring system is as follows³:
- Score 0: No breast tissue; ﬂat areola with no bud
- Score 1: Breast tissue < 5 mm; ﬂat areola with no bud
- Score 2: Breast tissue 5 to 10 mm; ﬂat areola with no bud
- Score 3: Breast tissue > 10 mm; raised areola with no bud
- Score 4: Breast tissue > 10 mm; raised areola with bud
- Score 5: Breast tissue > 10 mm; raised areola with large bud
The average score for term newborns is 2.5 for girls and 2.0 for boys. The score tends to be higher for heavier babies and lower for lighter babies. The score also tends to be higher for babies who were exposed to higher levels of maternal hormones during pregnancy, such as those whose mothers had diabetes, preeclampsia, or multiple gestation³⁴.
A score of 0 indicates that there is no breast tissue at all, and the areola is ﬂat with no bud. This finding can indicate preterm gestational age, as breast development usually starts before birth and progresses with increasing gestational age. Preterm newborns may have delayed or incomplete breast development due to insufficient exposure to maternal hormones or immature development of their own hormonal system³⁵.
Therefore, the nurse should identify this finding as indicating preterm gestational age and monitor the newborn for any other signs of prematurity, such as low birth weight, small head size, thin skin, low body temperature, respiratory distress, or feeding difficulties. The nurse should also provide appropriate care and support to the newborn and the parents according to the hospital protocol³⁵.

- b) Ambiguous secondary sex characteristics are physical features that do not clearly match the typical male or female pattern, such as genitalia, hair distribution, or voice pitch. They can be caused by genetic disorders, hormonal imbalances, or environmental inﬂuences. Ambiguous secondary sex characteristics do not aﬀect breast development in newborns, as breast tissue is present in both sexes and is inﬂuenced by maternal hormones rather than sex hormones¹ .
- c) Decreased maternal hormones during pregnancy can aﬀect breast development in newborns, but not in the way described. Decreased maternal hormones during pregnancy can cause lower breast scores in newborns, as they may have less stimulation of their breast tissue from the placenta. However, this does not mean that they have no breast tissue at all or a ﬂat areola with no bud. They may still have some degree of breast development depending on their gestational age, sex, weight, and exposure to their own hormones³⁴.
- d) Congenital anomaly is a term that refers to any structural or functional abnormality that is present at birth. Congenital anomalies can aﬀect any part of the body and can have various causes, such as genetic mutations, chromosomal abnormalities, infections, drugs, or environmental factors. Congenital anomalies can aﬀect breast development in newborns, but not in the way described. Congenital anomalies that aﬀect breast development in newborns usually cause abnormal or absent nipples or breasts, such as nipple hypoplasia (underdeveloped nipples), athelia (absence of nipples), amastia (absence of breasts), or polymastia (extra breasts). These anomalies do not cause a ﬂat areola with no bud .

Correct Answer is ["3"]

Explanation

Use the following formula to calculate the amount of gentamicin to administer:

Volume (mL) = Dose (mg) / Concentration (mg/mL)

First, I need to convert the client's weight from pounds to kilograms. One pound is equal to 0.4536 kilograms. Therefore, 132 lb is equal to 132 x 0.4536 = 59.8752 kg.

Next, I need to multiply the client's weight by the prescribed dose of gentamicin per kilogram. The prescribed dose is 2 mg/kg, so the total dose is 2 x 59.8752 = 119.7504 mg.

Finally, I need to divide the total dose by the concentration of gentamicin in the injection. The concentration is 40 mg/mL, so the volume is 119.7504 / 40 = 2.99376 mL.

To round the answer to the nearest whole number, I need to look at the first decimal place. If it is 5 or more, I round up; if it is less than 5, I round down. In this case, the first decimal place is 9, which is more than 5, so I round up. Therefore, the final answer is 3 mL.

The nurse should administer 3 mL of gentamicin injection to the client.

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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 performing an assessment for a newborn and notes breast tissue that has a ﬂat areola with no bud. The nurse should identify that this finding indicates which of the following conditions?

Correct Answer is A

Explanation

Correct Answer is ["3"]

Explanation

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