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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Step 1 is to calculate the total amount of Magnesium sulfate in the solution. This is done by multiplying the amount of Magnesium sulfate per mL (which is 50g/L or 0.05g/mL) by the total volume of the solution (which is 1000mL). So, 0.05g/mL × 1000mL = 50g.
Step 2 is to calculate the rate of the IV pump. The maintenance dose is 2g/hr. So, if there are 50g in 1000mL, then 2g would be in (2g ÷ 50g) × 1000mL = 40mL. Therefore, the IV pump should be set at 40 mL/hr.
Correct Answer is []
Explanation
The client is most likely experiencing Normal labor progression. The retraction of the fetal head against the maternal perineum, regular and progressing contractions, and full dilation of the cervix are all signs of normal labor progression.
Actions: The nurse should:
1. Encourage the client to push during contractions. This will help the baby move down the birth canal.
2. Monitor fetal heart rate. This is crucial to ensure the baby is not in distress.
Parameters: The nurse should monitor:
1. Frequency of contractions. This will help assess the progress of labor.
2. Fetal heart rate. Any abnormalities could indicate fetal distress, which would require immediate medical attention.
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