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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Quickening: Quickening is the term used to describe the first perception of fetal movements by the pregnant woman. It typically occurs between 16 to 20 weeks of gestation, which aligns with the client's statement about feeling fluttering movements at 18 weeks.
B) Ballottement: Ballottement is a physical examination technique performed by a healthcare provider to assess the fetus's position in the uterus. It is not related to the client's perception of fetal movement.
C) Chloasma: Chloasma refers to hyperpigmented skin areas that can appear during pregnancy due to hormonal changes. It is not related to fetal movement.
D) Lightening: Lightening refers to the descent of the fetal head into the maternal pelvis, which typically occurs in the third trimester. It is not related to the feeling of fetal movements by the mother.
Correct Answer is B
Explanation
Choice A reason:
Monitoring weight gain is correct because appropriate weight gain helps support fetal growth and reduces risks of complications such as gestational diabetes and preeclampsia.
Choice B reason:
Using nonprescription medications without provider approval is unsafe since many over-the-counter drugs (like NSAIDs or decongestants) can harm the fetus. This shows a need for further teaching.
Choice C reason:
Telling the provider before using home remedies is appropriate, as some herbs or supplements may be unsafe in pregnancy.
Choice D reason:
Reducing stress is correct because high maternal stress can negatively affect pregnancy outcomes and fetal development.
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