A nurse on an antepartum unit is reviewing the medical records for four clients. Which of the following clients should the nurse assess first?

A client who has placenta previa and a hematocrit of 36%.

A client who has hyperemesis gravidarum and a sodium level of 110 mEq/L.

A client who has diabetes mellitus and an HbA1c of 5.8%.

A client who has preeclampsia and a creatinine level of 1.1 mg/dL.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

A client with placenta previa and a hematocrit of 36% should be monitored closely due to the risk of bleeding, but it is not an immediate priority compared to the client with hyperemesis gravidarum and a low sodium level.

Choice B rationale:

Hyperemesis gravidarum is a severe form of morning sickness characterized by excessive vomiting, leading to dehydration and electrolyte imbalances. A sodium level of 110 mEq/L is dangerously low and requires immediate attention to correct the electrolyte disturbance and prevent further complications.

Choice C rationale:

A client with diabetes mellitus and an HbA1c of 5.8% is within a normal range, indicating good glycemic control. This client's condition can be managed on an outpatient basis and does not require urgent assessment compared to the others.

Choice D rationale:

A client with preeclampsia and a creatinine level of 1.1 mg/dL should be closely monitored, but it is not the priority over the client with hyperemesis gravidarum and severe electrolyte imbalance.

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Correct Answer is C

Explanation

Choice A rationale:

If both the mother and the father are Rh positive, there is no risk of hemolytic disease in the newborn due to Rh incompatibility. Hemolytic disease of the newborn occurs when the mother is Rh negative and the father is Rh positive.

Choice B rationale:

When the mother is Rh positive and the father is Rh negative, there is no risk of hemolytic disease in the newborn. Hemolytic disease results from Rh incompatibility, which occurs when the mother is Rh negative, and the father is Rh positive.

Choice C rationale:

This is the correct answer. Hemolytic disease of the newborn occurs when the mother is Rh negative, and the father is Rh positive. In such cases, the baby may inherit the Rh factor from the father, leading to Rh incompatibility between the mother and the baby's blood, potentially causing hemolytic disease.

Choice D rationale:

If both the mother and the father are Rh negative, there is no risk of hemolytic disease in the newborn due to Rh incompatibility. Hemolytic disease of the newborn occurs when the mother is Rh negative and the father is Rh positive.

A. Continue to monitor the client. B. Discontinue the oxytocin. C. Assist the client to lay on her right side. D. Administer oxygen at 8 L/min per mask.

Correct Answer is A

Explanation

The correct answer is choiceA. Continue to monitor the client.

Choice A rationale:

Early decelerations are typically benign and are caused by fetal head compression during contractions.They usually do not require any specific intervention other than continued monitoring to ensure they remain early decelerations and do not progress to more concerning patterns.

Choice B rationale:

Discontinuing oxytocin is not necessary for early decelerations, as they are not indicative of fetal distress.Oxytocin would be discontinued if there were signs of more severe decelerations or other complications.

Choice C rationale:

Assisting the client to lay on her right side is not specifically required for early decelerations.This position change is more commonly used for variable or late decelerations to improve uteroplacental blood flow.

Choice D rationale:

Administering oxygen at 8 L/min per mask is not needed for early decelerations.Oxygen is typically reserved for situations where there is evidence of fetal hypoxia or distress.

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A nurse on an antepartum unit is reviewing the medical records for four clients. Which of the following clients should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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