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 A, B, D, C
Explanation
- Compressing the bulb syringe before placing it in the newborn's mouth or nose creates a vacuum that allows the suctioning of the mucus¹².
- Placing the bulb syringe in the newborn's mouth first helps clear the oral airway and prevent aspiration of mucus into the lungs¹². The nozzle of the bulb syringe should be gently inserted into the corner of the mouth, not the center, to avoid stimulating the gag reflex¹².
- Using the bulb syringe to suction the newborns nose helps clear the nasal airway and improve breathing¹². The nozzle of the bulb syringe should be gently inserted into one nostril at a time, and not too far, to avoid injuring the nasal mucosa¹².
- Assessing the newborn for reflex bradycardia helps monitor for any adverse effects of suctioning, such as a decrease in heart rate due to vagal stimulation¹³. Reflex bradycardia can cause hypoxia and acidosis in newborns, and may require oxygen administration or resuscitation³. The normal heart rate for a newborn is 120 to 160 beats per minute³.
Correct Answer is C
Explanation
Postpartum hemorrhage (PPH) is severe vaginal bleeding after childbirth. It can occur within 24 hours of delivery (primary PPH) or up to 12 weeks postpartum (secondary PPH) ¹. PPH can cause serious complications and even death if not treated promptly and effectively¹.
The client in the question is at risk for PPH because she has a rapid labor and a high degree of cervical dilation. These factors can cause uterine atony, which is the failure of the uterus to contract and compress the blood vessels after delivery. Uterine atony is the most common cause of PPH, accounting for up to 80% of cases². Other risk factors for PPH include placental abruption, placenta previa, overdistended uterus, multiple pregnancy, prolonged labor, operative delivery, retained placenta, coagulation disorders, and infection²³.
a) Hyperemesis gravidarum is a condition of severe nausea and vomiting during pregnancy that can cause dehydration, electrolyte imbalance, weight loss, and nutritional deficiencies. It usually occurs in the first trimester and resolves by the second trimester. It is not related to PPH⁴.
b) Ectopic pregnancy is a condition where the fertilized egg implants outside the uterus, usually in the fallopian tube. It can cause abdominal pain, vaginal bleeding, and rupture of the tube. It is a medical emergency that requires prompt diagnosis and treatment. It occurs in early pregnancy and cannot be diagnosed at 12 weeks of gestation by amniocentesis.
d) Incompetent cervix is a condition where the cervix dilates prematurely and painlessly during pregnancy, leading to preterm labor and delivery or pregnancy loss. It usually occurs in the second trimester and can be treated with cervical cerclage or progesterone. It is not associated with PPH.
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