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.
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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Betamethasone is a corticosteroid used to enhance lung maturity in preterm infants and has no role in treating uterine atony.
Choice B rationale:
Hydralazine is an antihypertensive medication used to lower blood pressure and is not indicated for the management of uterine atony.
Choice C rationale:
Terbutaline is a tocolytic medication used to relax the uterus and delay preterm labour. It is not used to address uterine atony.
Choice D rationale:
Methylergonovine is a uterotonic medication commonly used to treat uterine atony by causing uterine contractions and controlling postpartum bleeding. It helps the uterus contract and prevents further blood loss.
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.
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