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
Explanation
A newborn who is exposed to HIV perinatally should be bathed and cleansed of maternal secretions as soon as possible after birth to reduce the risk of HIV transmission through the skin or mucous membranes¹². The newborn should also receive antiretroviral prophylaxis within six hours of delivery, preferably within two hours¹². The type and duration of prophylaxis depend on the maternal and infant factors that influence the risk of HIV transmission, such as maternal viral load, antiretroviral therapy, mode of delivery, and infant gestational age¹²³. The newborn should also undergo HIV testing at birth, at 14 to 21 days of age, at one to two months of age, and at four to six months of age¹².
The other options are incorrect because:
b) Initiating contact precautions for the newborn is not necessary or recommended. Contact precautions are used to prevent the spread of infections that are transmited by direct or indirect contact with the patient or the patient's environment. HIV is not transmited by casual contact, and standard precautions are sufficient to prevent exposure to blood or body fluids that may contain HIV¹².
c) Administering intravenous antibiotics to the newborn is not indicated for HIV prevention. Antibiotics are used to treat bacterial infections, not viral infections like HIV. Antibiotics may be given to the newborn for other reasons, such as suspected sepsis or chorioamnionitis, but they do not affect the risk of HIV transmission¹².
d) Encouraging the mother to breastfeed her newborn is contraindicated for HIV prevention. Breastfeeding can transmit HIV from the mother to the infant through breast milk, especially if the mother has a high viral load, mastitis, cracked nipples, or oral lesions in the infant. In resource-limited settings where formula feeding may not be feasible or safe, breastfeeding with maternal or infant antiretroviral therapy may be considered, but in developed countries where safe alternatives are available, breastfeeding is not recommended for mothers with HIV infection¹².
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 .
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