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 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.
A client who has missed a period and reports vaginal spotting.
The Correct Answer is C
Choice A rationale
A cough and fever in a client at 38 weeks of gestation could indicate an infection, which should be addressed promptly. However, it is not as immediately life-threatening as painless vaginal bleeding at 28 weeks of gestation, which could indicate a serious complication such as placental abruption.
Choice B rationale
Nausea and vomiting at 14 weeks of gestation are common symptoms of early pregnancy and, while uncomfortable, are not usually a sign of a serious problem. This client should be seen, but not before a client with a potentially life-threatening condition like painless vaginal bleeding.
Choice C rationale
Painless vaginal bleeding at 28 weeks of gestation is a serious symptom that could indicate placental abruption, a condition where the placenta detaches from the uterus, which can be life-threatening for both the mother and the baby. This client should be seen first.
Choice D rationale
Vaginal spotting in a client who has missed a period could indicate early pregnancy or a number of other conditions. While this client should be seen to confirm the cause of the spotting, it is not as immediately urgent as painless vaginal bleeding at 28 weeks of gestation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice C rationale
While moderate caffeine consumption is generally considered safe during pregnancy, it’s important to note that caffeine is a stimulant and can increase heart rate and blood pressure, which can potentially affect the baby. Some studies also suggest that high caffeine intake may increase the risk of preterm birth or low birth weight. Therefore, it’s often recommended that pregnant women limit their caffeine intake.
Correct Answer is A
Explanation
The correct answer is choice a. Excessive uterine enlargement.
Choice A rationale:
Hydatidiform mole, also known as a molar pregnancy, often presents with excessive uterine enlargement. This is due to the abnormal growth of trophoblastic tissue, which can cause the uterus to be larger than expected for gestational age.
Choice B rationale:
An irregular fetal heart rate is not typically associated with a hydatidiform mole because there is usually no viable fetus present in this condition.
Choice C rationale:
A rapid decline in human chorionic gonadotropin (hCG) levels is not expected. Instead, hCG levels are usually abnormally high due to the trophoblastic tissue proliferation.
Choice D rationale:
Profuse, clear vaginal discharge is not a characteristic finding of a hydatidiform mole. Instead, vaginal bleeding or discharge that may be brownish and resemble prune juice is more common.
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