A nurse in an antepartum unit is triaging clients. Which of the following clients should the nurse see first?

A client who is at 38 weeks of gestation and reports a cough and fever.

A client who has missed a period and reports vaginal spotting.

A client who is at 14 weeks of gestation and reports nausea and vomiting.

A client who is at 28 weeks of gestation and reports painless vaginal bleeding.

Answer and Explanation

The Correct Answer is D

A. A client at 38 weeks of gestation with a cough and fever may have an infection, which is concerning, but it is not immediately life-threatening. The nurse should assess this client soon, but it is not the highest priority.

B. A client who has missed a period and reports vaginal spotting could be experiencing an early pregnancy complication, such as a miscarriage or ectopic pregnancy. This situation requires attention, but it is not as urgent as painless vaginal bleeding in the third trimester.

C. A client at 14 weeks of gestation with nausea and vomiting is likely experiencing common pregnancy symptoms. While these symptoms can be uncomfortable and require management, they are not typically urgent.

D. A client at 28 weeks of gestation with painless vaginal bleeding could be experiencing placenta previa or another serious condition that poses an immediate risk to both the mother and the fetus. This situation requires urgent assessment and intervention.

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Correct Answer is C

Explanation

The correct answer is: c. 42022

Choice A: 40122

Reason: This choice is incorrect because it indicates 4 pregnancies (correct), 0 term births (correct), 1 preterm birth (correct), 2 abortions (correct), but 2 living children (incorrect). The client has 2 living children, which is correct, but the term and preterm counts are not accurate.

Choice B: 20020

Reason: This choice is incorrect because it indicates 2 pregnancies (incorrect), 0 term births (correct), 0 preterm births (incorrect), 2 abortions (correct), and 0 living children (incorrect). The client has had 4 pregnancies, 1 preterm birth, and 2 living children.

Choice C: 42022

Reason: This choice is correct. It indicates 4 pregnancies (current pregnancy, elective abortion, twins, spontaneous abortion), 0 term births, 2 preterm births (twins at 36 weeks), 2 abortions (elective at 9 weeks, spontaneous at 15 weeks), and 2 living children (twins).

Choice D:

The GTPAL system is used to assess a client's obstetric history:

G (Gravida): The total number of pregnancies, including the current one.
T (Term births): The number of pregnancies carried to at least 37 weeks.
P (Preterm births): The number of pregnancies delivered between 20 and 36 weeks, 6 days.
A (Abortions): The number of pregnancies ending before 20 weeks (spontaneous or elective).
L (Living children): The number of children currently alive.

For this client:

G (Gravida): 4 (one elective abortion, one twin pregnancy, one spontaneous abortion, and the current pregnancy).

T (Term births): 0 (the twin pregnancy was delivered at 36 weeks, which is preterm).
P (Preterm births): 1 (twins delivered at 36 weeks count as one preterm birth).
A (Abortions): 2 (one elective abortion at 9 weeks, one spontaneous abortion at 15 weeks).
L (Living children): 2 (the twins).

Thus, the GTPAL for this client is 4-0-1-2-2.

A. Assess the client's temperature. B. Assess the fetal heart rate and pattern. C. Record color and consistency of fluid in the chart. D. Evaluate the client for the presence of chills and increased uterine tenderness using palpation.

Correct Answer is B

Explanation

Choice A: Assessing the client's temperature is important, but it is not the priority immediately after an amniotomy. Fetal wellbeing takes precedence.

Choice B; After an amniotomy (artificial rupture of membranes), the priority nursing action is to assess the fetal heart rate and pattern. The procedure may cause changes in fetal heart rate and indicate fetal distress or cord compression, requiring immediate attention.

Choice C: Recording the color and consistency of fluid is relevant for documentation but does not address the immediate concern of fetal wellbeing.

Choice D: Evaluating the client for chills and uterine tenderness is not the priority after an amniotomy. Monitoring the fetal heart rate is crucial to detect any signs of distress.

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A nurse in an antepartum unit is triaging clients. Which of the following clients should the nurse see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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