How it Works
Try Naxlex NCLEX-RN (Free-Trial)

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.

A client who is at 34 weeks of gestation and is experiencing epigastric pain and headache.

B.

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

C.

A client who is at 38 weeks of gestation and is experiencing painful urination.

D.

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. 


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

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is D

Explanation

Choice A rationale:

The nurse does not need to obtain a sample of the discharge for laboratory testing at this point. Yellow discharge after circumcision is common and generally not a cause for immediate concern. Laboratory testing is not necessary for routine circumcision care.

Choice B rationale:

Applying povidone-iodine solution twice daily to the circumcision site is not recommended in this situation. Povidone-iodine may cause irritation and delay the natural healing process.

Generally, no specific cleaning solution is required for circumcision care unless otherwise indicated by a healthcare provider.

Choice C rationale:

Wiping the discharge away gently with a washcloth and warm water for the next 48 hours is not the most appropriate action. The circumcision site should be kept clean and dry, but actively wiping away the discharge may cause irritation and disrupt the natural healing process.

Correct Answer is C

Explanation

The correct answer is c. Ampicillin.

Rationale:

  • Group B Streptococcus (GBS) B-hemolyticis a bacterium that can colonize the vagina and rectum of pregnant women.While usually harmless to the mother,it can be passed to the newborn during birth and cause serious infections,including pneumonia,meningitis,and sepsis.
  • Ampicillinis thefirst-line antibioticrecommended by the Centers for Disease Control and Prevention (CDC) for theprevention of GBS disease in newborns.It belongs to thepenicillin classof antibiotics,which are highly effective against GBS and generally well-tolerated by pregnant women and newborns.
  • Doxycyclineis not recommended for GBS prophylaxis due to its poor penetration into amniotic fluid and potential for causing tooth discoloration and bone development problems in newborns.
  • Cefotetanis an alternative option for women with penicillin allergy,but ampicillin is still preferred due to its lower cost and broader spectrum of activity against GBS strains.
  • Fluconazoleis an antifungal medication and has no activity against GBS bacteria.

Detailed Rationale for Each Choice:

a. Doxycycline:

  • Rationale against:
    • Poor penetration into amniotic fluid:Doxycycline does not effectively reach the amniotic sac,where the baby is surrounded,and therefore may not adequately protect the newborn from GBS infection.
    • Adverse effects in newborns:Doxycycline can cause tooth discoloration and bone development problems in infants exposed in utero.

b. Cefotetan:

  • Rationale for:
    • Alternative for penicillin allergy:Cefotetan is a cephalosporin antibiotic effective against GBS and can be used in women with penicillin allergy.
  • Rationale against:
    • Second-line option:Ampicillin is the preferred choice due to its lower cost and broader spectrum of activity against GBS strains.

c. Ampicillin:

  • Rationale for:
    • First-line antibiotic:Ampicillin is the CDC-recommended first-line antibiotic for GBS prophylaxis due to its:
      • High effectiveness against GBS:Ampicillin has a broad spectrum of activity against GBS strains.
      • Good safety profile:Ampicillin is generally well-tolerated by pregnant women and newborns.
      • Cost-effectiveness:Ampicillin is a relatively inexpensive antibiotic compared to other options.

d. Fluconazole:

  • Rationale against:
    • Antifungal medication:Fluconazole is an antifungal medication and has no activity against GBS,which is a bacterium.

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

Register