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 34 weeks of gestation and is experiencing epigastric pain and headache.

A client who is at 12 weeks of gestation and is experiencing nausea and vomiting.

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 A

Choice A rationale:

The nurse should assess this client first as they are at 34 weeks of gestation and experiencing epigastric pain and headache. These symptoms could be indicative of preeclampsia, a serious pregnancy complication characterized by high blood pressure and organ damage. Preeclampsia requires immediate assessment and intervention to prevent further complications.

Choice B rationale:

Nausea and vomiting are common symptoms during the first trimester of pregnancy, and at 12 weeks of gestation, it is less likely to be a critical issue compared to potential preeclampsia.

Choice C rationale:

Painful urination may indicate a urinary tract infection, which can be important to assess and treat, but it is not as urgent as potential signs of preeclampsia in a client at 34 weeks of gestation.

Choice D rationale:

Cramping and spotting can be normal signs of impending labor, especially at 39 weeks of gestation. While it's important to assess this client, it is not the priority over potential preeclampsia in a client at 34 weeks of gestation with symptoms of epigastric pain and headache.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

The correct answer is choice B. Single palmar creases.

Choice A rationale:

Rust-stained urine is typically due to urate crystals and is common in newborns. It usually resolves on its own and is not a cause for concern.

Choice B rationale:

Single palmar creases can be associated with certain genetic conditions, such as Down syndrome. This finding should be reported to the provider for further evaluation.

Choice C rationale:

Subconjunctival hemorrhage is a common finding in newborns due to the pressure changes during delivery. It usually resolves without intervention and is not typically a cause for concern.

Choice D rationale:

Transient circumoral cyanosis is often seen in newborns and can occur when the baby is crying or feeding. It usually resolves on its own and is not typically a cause for concern.

A. Urine output 20 mL/hr. B. Hypertension. C. Hyperglycemia. D. Respiratory rate 16/min.

Correct Answer is A

Explanation

Choice A rationale:

This manifestation, urine output of 20 mL/hr, is an adverse reaction to magnesium sulfate administration. Magnesium sulfate can lead to decreased urine output, and it is essential for the nurse to monitor the client's urinary output closely. Low urine output may indicate decreased kidney function, which can be a sign of magnesium toxicity.

Choice B rationale:

Hypertension is expected in a client with preeclampsia, and magnesium sulfate is used to help manage and prevent seizures in these cases. While it is essential to monitor and manage hypertension during pregnancy, it is not considered an adverse reaction to magnesium sulfate.

Choice C rationale:

Hyperglycemia is not a common adverse reaction to magnesium sulfate. Magnesium sulfate may cause central nervous system depression, muscle weakness, and respiratory depression, but it does not typically cause hyperglycemia.

Choice D rationale:

A respiratory rate of 16/min is within the normal range for an adult and is not indicative of an adverse reaction to magnesium sulfate. Magnesium sulfate can cause respiratory depression at higher doses, but a respiratory rate of 16/min does not raise immediate concerns.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?

Correct Answer is B

Explanation

A nurse is caring for a client who is at 30 weeks of gestation and is receiving magnesium sulfate for preeclampsia. The nurse should recognize which of the following manifestations as an adverse reaction to the medication?

Correct Answer is A

Explanation

A nurse is calculating the estimated date of delivery for a client who reports that the first day of her last menstrual period was August 10. Using Nägele's Rule, which of the following is the client's estimated date of delivery?

A nurse is providing prenatal teaching to a client who practices a vegan diet and is trying to increase her intake of vitamin B12. Which of the following foods should the nurse recommend?

A nurse is providing teaching about increasing dietary fibre to an antepartum client who reports constipation. Which of the following food selections has the highest fibre content per cup?

A nurse is monitoring a client who is undergoing a nonstress test at 35 weeks of gestation. Which of the following findings requires intervention by the nurse?

A nurse is teaching a prenatal client about listeriosis and dietary modifications during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client who is in labour. Which of the following findings should prompt the nurse to reassess the client?

A nurse is developing an educational program about hemolytic disease in newborns for a group of newly licensed nurses. Which of the following genetic information should the nurse include in the program as a cause of hemolytic disease?

A nurse is reviewing the medical record of a client who had a vaginal delivery 3 hr ago. Which of the following findings places the client at risk for postpartum haemorrhage?(Select all that apply.)