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

A client who is at 34 weeks of getation and reports double vision

A client who is at 38 weeks of gestation and reports leg cramps

A client who is at 8 weeks of gestation and reports excessive salivation

A client who is at 24 weeks of gestation and reports periodic finger numbness

Answer and Explanation

The Correct Answer is A

A. Double vision at 34 weeks of gestation is a potential sign of preeclampsia, which can lead to severe complications such as seizures (eclampsia), stroke, or organ damage. This client requires immediate assessment.
B. Leg cramps are common in late pregnancy due to pressure on nerves and changes in circulation. This is not an urgent concern.
C. Excessive salivation (ptyalism) is benign and can occur in early pregnancy due to hormonal changes. It does not require immediate assessment.
D. Periodic finger numbness is often due to carpal tunnel syndrome, a common non-urgent condition in pregnancy caused by fluid retention.

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Correct Answer is C

Explanation

A. Have the client hold their breath during the examination. This is not recommended, as slow, deep breathing helps the client relax and reduces discomfort.
B. Ensure that the client's bladder is full. The bladder should be emptied before the exam to enhance comfort and allow better access for the provider.
C. Instruct the client to bear down when the speculum is inserted. This helps relax the pelvic muscles and makes insertion easier, reducing discomfort.
D. Place the client in modified Sims' position. The lithotomy position is the correct positioning for a pelvic examination, not modified Sims'.

A. Small clots with tissue in the urine B. Dark red urine C. Urinary output 25 mL/hr D. Pain of 8 on a scale of 0 to 10

Correct Answer is A

Explanation

A. Small clots with tissue in the urine. It is expected for a client 2 days post-TURP to have small clots and tissue debris in the urine as part of the healing process. Continuous bladder irrigation (CBI) often helps clear these.

B. Dark red urine. Bright red or dark red urine can indicate active bleeding, which is not expected 2 days post-op and requires immediate intervention.

C. Urinary output 25 mL/hr. This is too low (normal output should be at least 30 mL/hr) and could indicate catheter blockage, dehydration, or renal impairment, which is not expected.

D. Pain of 8 on a scale of 0 to 10. Mild discomfort is expected, but severe pain (8/10) is abnormal and could indicate bladder spasms, catheter blockage, or another complication requiring intervention.

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A nurse in 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 preparing a client for a pelvic examination. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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