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 B

Explanation

Rationale:

A. Massaging the client's fundus is not indicated for hypotension following epidural anesthesia.

Fundal massage is typically performed to prevent or manage uterine atony and postpartum hemorrhage.

B. Turning the client to a side-lying position is a recommended intervention for hypotension following epidural anesthesia. This position helps improve venous return to the heart and can help alleviate hypotension by reducing aortocaval compression.

C. Applying oxygen via nasal cannula may be indicated if the client is experiencing respiratory distress, but it is not the primary intervention for hypotension.

D. Assisting the client to empty their bladder may be appropriate to relieve urinary retention but is not the priority intervention for hypotension.

A. Administer oxygen via nonrebreather mask at 8 L/min. B. Cover the umbilical cord with a sterile saline-saturated towel. C. Initiate an infusion of IV fluids for the client. D. Perform a vaginal examination by applying upward pressure on the presenting part.

Correct Answer is D

Explanation

Rationale:

A. Administering oxygen via a nonrebreather mask may be indicated for fetal distress, but the priority in this situation is to protect the umbilical cord from compression and minimize fetal compromise.

B. Cover the umbilical cord with a sterile saline-saturated towel is an appropriate action to prevent the cord from drying out and to reduce infection butimmediate focus should be on relieving pressure on the umbilical cord to ensure adequate fetal perfusion.

C. Initiate an infusion of IV fluids for the client can help stabilize maternal hemodynamics, but it does not directly address the umbilical cord compression. Relieving the pressure on the cord is the immediate intervention to prevent fetal hypoxia.

D. Perform a vaginal examination by applying upward pressure on the presenting part is the priority intervention. In cases of umbilical cord prolapse, the nurse must perform a vaginal examination and apply upward manual pressure on the presenting part (usually the fetal head) to lift it off the umbilical cord. This action relieves compression on the cord and restores blood flow and oxygen delivery to the fetus until an emergency delivery can be performed.

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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 is hypotensive following the administration of epidural anesthesia. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who reports spontaneous rupture of membranes. The nurse observes fetal bradycardia on the FHR tracing and notices that the umbilical cord is protruding. After calling for assistance and notifying the provider, which of the following actions should the nurse take next?

Correct Answer is D

Explanation

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