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 ["-"]
Explanation
The nurse is observing a potential case of shoulder dystocia, a condition where the baby’s head has been delivered but one of the shoulders becomes stuck behind the mother’s pelvic bone. The nurse should monitor the mother’s vital signs and the baby’s heart rate. The nurse should call for immediate assistance, perform maneuvers to help deliver the baby, and prepare for a potential emergency cesarean section if necessary.
Correct Answer is A
Explanation
The correct answer is A. Shoulder dystocia. Retraction of the fetal head against the maternal perineum as the head is birthed is a classic sign of shoulder dystocia. This is a birth complication where the baby’s shoulder gets stuck behind the mother’s pelvic bone during delivery.
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