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
Hemolytic disease of the newborn (HDN) is a condition that occurs when there is an incompatibility between the blood types of the mother and the baby. It causes the mother's immune system to produce antibodies that attack and destroy the baby's red blood cells, leading to anemia, jaundice, organ enlargement, and other complications¹.
One of the most common causes of HDN is Rh incompatibility. This happens when the mother is Rh negative and the baby is Rh positive. The Rh factor is a protein that can be present or absent on the surface of red blood cells. People who have the protein are Rh positive and people who do not have it are Rh negative
Rh incompatibility can cause HDN when the baby's Rh positive blood cells cross the placenta and enter the mother's bloodstream. This can happen during delivery, miscarriage, abortion, or invasive prenatal testing. The mother's immune system recognizes the baby's blood cells as foreign and produces antibodies against them. These antibodies can cross back to the baby's bloodstream and attack the baby's red blood cells, causing hemolysis (breakdown) and anemia².
HDN due to Rh incompatibility usually does not affect the first pregnancy, because the mother has not been exposed to Rh positive blood before and has not developed antibodies yet. However, it can affect subsequent pregnancies with Rh positive babies, because the mother has become sensitized and has antibodies ready to attack².
The other options are not causes of HDN:
- a) The mother and the father are both Rh negative. This is not a cause of HDN because both parents have the same Rh factor and there is no incompatibility between them. The baby will also be Rh negative and will not trigger an immune response from the mother².
- b) The mother and the father are both Rh positive. This is not a cause of HDN because both parents have the same Rh factor and there is no incompatibility between them. The baby will also be Rh positive and will not trigger an immune response from the mother².
- c) The mother is Rh positive and the father is Rh negative. This is not a cause of HDN because the mother has a dominant Rh factor and will not produce antibodies against it. The baby will either be Rh positive or Rh negative, depending on whether they inherit the father's gene or not. In either case, the baby's blood type will not trigger an immune response from the mother².
Correct Answer is D
Explanation
An indirect Coombs' test, also known as an indirect antiglobulin test, is used to detect antibodies in your bloodstream that could attach to red blood cells¹². It is used as a screening process to see how you'll react to a blood transfusion². An indirect Coombs' test is also routinely given as part of prenatal testing to see if you have antibodies against Rh-positive blood¹. If you have an Rh-negative blood type and your baby has an Rh-positive blood type, then your immune system could make antibodies that attack your baby's red blood cells¹. This can cause a condition called Rh disease, which can lead to anemia, jaundice or other serious health problems for your baby¹. The indirect Coombs' test can help prevent or treat this problem by detecting the presence of Rh-positive antibodies in your blood¹².
The other options are incorrect because they describe different tests or purposes:
a) The amount of amniotic fluid around the fetus is measured by an ultrasound scan, not by a blood test.
b) The risk of hypoglycemia (low blood sugar) after birth is assessed by measuring the baby's blood glucose level, not by a maternal blood test.
c) The blood flow in the fetus and placenta is studied by a Doppler ultrasound scan, not by a blood test.
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