A nurse at an antepartum clinic is caring for four clients. Which of the following clients should the nurse assess first?

A client who is at 36 weeks of gestation and reports back pain following intercourse

A client who is at 8 weeks of gestation and reports severe vomiting

A client who is at 10 weeks of gestation and reports frequent urination

A client who is at 24 weeks of gestation and reports periodic tingling of the fingers

Answer and Explanation

The Correct Answer is B

Rationale:

A. Back pain following intercourse at 36 weeks of gestation may be common and is not typically indicative of an urgent issue.

B. Severe vomiting in early pregnancy could indicate hyperemesis gravidarum, which may require immediate assessment and intervention to prevent dehydration and electrolyte imbalances.

C. Frequent urination at 10 weeks of gestation is common due to hormonal changes and increased pressure on the bladder from the growing uterus, but it does not typically require immediate assessment unless accompanied by other concerning symptoms.

D. Periodic tingling of the fingers at 24 weeks of gestation could be due to carpal tunnel syndrome, which is common in pregnancy but does not usually require urgent assessment unless severe or accompanied by other symptoms.

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Correct Answer is C

Explanation

Rationale:

A. Applying an ice pack to the incision site is not indicated for addressing vaginal bleeding after cesarean birth and may not effectively address the underlying cause.

B. Replacing the surgical dressing is not the first action to take when assessing vaginal bleeding after cesarean birth. The priority is to evaluate the client's condition and identify the cause of the bleeding.

C. Evaluating urinary output is important to assess for urinary retention, which can contribute to uterine atony and postpartum bleeding. A full bladder can interfere with uterine contraction and lead to increased bleeding.

D. Administering a lactated Ringer's IV bolus may be indicated if the client is hypovolemic due to excessive bleeding, but it is not the first action to take. Assessing urinary output and addressing potential causes of bleeding take precedence.

A. Maintain a low stimulation environment. B. Plan to administer naloxone. C. Instruct the parent to avoid breastfeeding D. Instruct the parent to avoid eye contact with the newborn during feeding E. Perform Ballard newborn screening each shift. F. Weigh the newborn daily. G. Swaddle the newborn with flexed extremities

Correct Answer is ["A","C","E","F","G"]

Explanation

Rationale:

A. Newborns with neonatal abstinence syndrome (NAS) are often irritable and hypersensitive to stimuli. Keeping the environment calm and quiet can help minimize their discomfort.

B. Naloxone is not routinely used in the management of NAS unless there is evidence of severe respiratory depression or opioid overdose, which is not indicated in this scenario.

C. Maternal opioid use and positive urine drug screens for methadone may contraindicate breastfeeding due to the potential transmission of opioids to the infant through breast milk. It's essential to consult with healthcare providers regarding the safest feeding option for the newborn.

D. Eye contact during feeding is essential for bonding between the parent and the newborn and should not be discouraged unless medically necessary.

E. Ballard newborn screening helps assess the newborn's gestational age and guide appropriate care for neonates with NAS, as they may require specialized management.

F. Daily weighing helps monitor the newborn's hydration status and overall well-being, which is crucial in managing NAS and ensuring adequate nutrition.

G. Swaddling can provide comfort to newborns with NAS by mimicking the womb environment and reducing their agitation.

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A nurse at an antepartum clinic is caring for four clients. Which of the following clients should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who delivered by cesarean birth 6 hr ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

Correct Answer is ["A","C","E","F","G"]

Explanation

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