As a nurse in an antepartum unit performing triage, which client should be prioritized?

A client who has missed a menstrual cycle and reports vaginal spotting.

A client who is at 28 weeks of gestation and reports painless vaginal bleeding.

A client who is at 38 weeks of gestation and reports symptoms of a cough and fever.

A client who is at 14 weeks of gestation and reports experiencing nausea and vomiting.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Missing a menstrual cycle and reporting vaginal spotting could indicate early pregnancy or other non-emergency conditions. While this client should be evaluated, it is not the highest priority.
Choice B rationale
A client at 28 weeks of gestation reporting painless vaginal bleeding could be experiencing placenta previa or placental abruption, both of which are obstetric emergencies. This client should be prioritized for immediate evaluation.
Choice C rationale
A client at 38 weeks of gestation reporting symptoms of a cough and fever may have an upper respiratory infection. While this should be evaluated, it is not the highest priority unless the client is in distress.
Choice D rationale
Nausea and vomiting are common in early pregnancy. A client at 14 weeks of gestation reporting these symptoms would need evaluation, but it is not the highest priority.

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Correct Answer is C

Explanation

Choice A reason:

Fetal head compression is associated with early decelerations, not late. Early decelerations are a normal finding during labor as the fetal head is compressed during contractions, leading to a vagal response that temporarily decreases the heart rate.

Choice B reason:

Umbilical cord compression leads to variable decelerations, not late. Variable decelerations can occur at any time during the contraction cycle and are caused by compression of the umbilical cord, which can restrict blood flow to the fetus.

The correct answer is C. Uteroplacental insufficiency.

Late decelerations are indicative of uteroplacental insufficiency, which is a condition where the placenta is not delivering enough oxygen and nutrients to the fetus.

Choice D reason:

Maternal bradycardia, which is a slower than normal heart rate in the mother, does not cause late decelerations in the fetus. Instead, maternal bradycardia can be a separate concern and does not directly affect the fetal heart rate pattern observed on the monitor.

A. Prepare the abdominal and perineal areas. B. Initiate IV access. C. Insert an indwelling urinary catheter. D. Witness the signature for informed consent for surgery.

Correct Answer is B

Explanation

Choice A rationale
Preparing the abdominal and perineal areas is not the priority nursing action for a client who has a large amount of painless, bright red vaginal bleeding at 38 weeks of gestation. This type of bleeding is suggestive of placenta previa, a condition where the placenta covers part or all of the cervix, preventing normal delivery. While preparing the abdominal and perineal areas may be necessary in preparation for delivery, it is not the immediate priority.
Choice B rationale
Initiating IV access is the priority nursing action for a client who has a large amount of painless, bright red vaginal bleeding at 38 weeks of gestation. This type of bleeding is suggestive of placenta previa, a condition where the placenta covers part or all of the cervix, preventing normal delivery. IV access allows for rapid administration of fluids and medications, which may be necessary to stabilize the client’s condition.
Choice C rationale
Inserting an indwelling urinary catheter is not the priority nursing action for a client who has a large amount of painless, bright red vaginal bleeding at 38 weeks of gestation. While a urinary catheter may be necessary in preparation for delivery or surgery, it is not the immediate priority.
Choice D rationale
Witnessing the signature for informed consent for surgery is not the priority nursing action for a client who has a large amount of painless, bright red vaginal bleeding at 38 weeks of gestation. While obtaining informed consent may be necessary before performing certain procedures or surgeries, it is not the immediate priority.

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As a nurse in an antepartum unit performing triage, which client should be prioritized?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?

Correct Answer is C

Explanation

Correct Answer is B

Explanation

A nurse is assessing a client who is pregnant for preeclampsia. Which of the following findings should indicate to the nurse that the client requires further evaluation for this disorder?

A nurse is preparing to administer methylergonovine IM to a client who has just had a vaginal delivery. The nurse should inform the client that this medication is intended to prevent which of the following conditions?

As a nurse in an antepartum unit performing triage, which client should be prioritized?

A nurse is caring for a client who is scheduled for a maternal serum alpha-fetoprotein test at 15 weeks of gestation. Which of the following explanations about this test should the nurse provide to the client?

A nurse in a prenatal clinic is caring for a pregnant client who inquires about her estimated date of birth (EDB). If the client’s last menstrual period started on July 27, what would be the client’s EDB? (Provide the date in MMDD format. For example, July 27 is 0727) .

A nurse is caring for a client who is 39 weeks pregnant and in active labor. The nurse detects the fetal heart tones above the client’s umbilicus at the midline. Which of the following positions should the nurse suspect the fetus is in?

A nurse is preparing an in-service program about preventing medication errors when transcribing a prescription. The nurse is using a dosage example of two tenths of a milligram. Which of the following examples should the nurse use to show appropriate transcription of this dosage?