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 D

Explanation

A) Retained bile in the liver results in delayed digestion: This statement is not related to the cause of heartburn.
B) Increased estrogen production causes increased secretion of hydrochloric acid: While hormonal changes during pregnancy can contribute to heartburn, it is specifically increased progesterone that leads to relaxation of the cardiac sphincter and delayed gastric emptying, which are more directly linked to heartburn.
C) Pressure from the growing uterus displaces the stomach: Uterine pressure on the stomach can lead to a feeling of fullness, but it is not the primary cause of heartburn during pregnancy.
D) Increased progesterone production causes relaxation of the smooth muscle relaxation of the cardiac sphincter and delayed gastric emptying: This is the correct answer. Increased progesterone levels during pregnancy relax the lower esophageal sphincter, leading to gastric acid reflux into the esophagus and causing heartburn.

A. Observe for the presence of a nuchal cord. B. Prepare to administer oxytocin. C. Observe for crowning. D. Apply fundal pressure.

Correct Answer is C

Explanation

A. Observe for the presence of a nuchal cord: While this is important, it is not specifically related to the finding of the fetal head at a certain station.
B. Prepare to administer oxytocin: Oxytocin is a hormone used to induce or augment labor, but there is no indication for its use based solely on the fetal head station.
C. Observe for crowning: The fetal head at 3+ station indicates significant descent, and crowning may occur soon. Crowning is the appearance of the fetal head at the vaginal opening and indicates that delivery is imminent.
D. Apply fundal pressure: Fundal pressure is not appropriate at this stage of labor and could cause harm.

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

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Naxlex Comprehensive Predictor Exams

A nurse in a prenatal clinic is caring for a client who is at 12 weeks gestation. The client asks about the cause of her heartburn. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vaginal examination. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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