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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
The nurse should not tell the client that she cannot have an amniocentesis until she is at least 35 years of age. Age is not the primary factor for determining the eligibility for an amniocentesis. Amniocentesis is typically performed when there is a medical indication, such as advanced maternal age, abnormal prenatal screening, or a family history of genetic disorders.
Choice B rationale:
The nurse should not schedule the amniocentesis for later today without further clarification from the provider. Scheduling medical procedures without the provider's approval is not within the nurse's scope of practice and could lead to potential risks.
Choice C rationale:
This is the correct answer. The nurse should explain to the client that amniocentesis is a procedure used to determine if the baby has genetic or congenital disorders. It involves the extraction of a small amount of amniotic fluid to analyze the fetal cells for genetic abnormalities.
Choice D rationale:
The nurse should not tell the client that her provider will schedule a chorionic villus sampling (CVS) to determine the sex of the baby. CVS is another prenatal diagnostic test, but its primary purpose is to detect genetic disorders early in pregnancy, not to determine the baby's sex.
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.
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