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 A
Explanation
Choice A rationale
A 38-year-old client who reports smoking one pack of cigarettes every day. Oral contraceptives are contraindicated in women who are over 35 years old and smoke. This is because the combination of oral contraceptives and smoking increases the risk of serious cardiovascular side effects, such as blood clots, stroke, or heart attack. These risks are even higher in women over 35 years old who smoke. Therefore, this client should not receive oral contraceptives due to the increased risk of these serious side effects.
Choice B rationale
A 28-year-old client who has a history of pelvic inflammatory disease. While pelvic inflammatory disease (PID) can lead to complications such as infertility and ectopic pregnancy, it is not a contraindication for the use of oral contraceptives. In fact, oral contraceptives can provide some protection against PID by causing changes in the cervix that make it more resistant to infection.
Choice C rationale
A 32-year-old client who has benign breast disease. Benign breast disease is not a contraindication for the use of oral contraceptives. While some studies have suggested a slightly increased risk of breast cancer in women who have used oral contraceptives, the risk appears to decrease over time once the contraceptives are stopped.
Choice D rationale
A 26-year-old client who has migraine headaches at the start of each menstrual cycle. While migraines can be a contraindication for the use of oral contraceptives, it generally applies to migraines with aura. Women who have migraines with aura have an increased risk of stroke when using oral contraceptives. However, for women who have migraines without aura, the benefits of using oral contraceptives usually outweigh the risks.
Correct Answer is B
Explanation
Choice A rationale
While bile does play a role in digestion, it is not retained in the liver. Instead, it is produced by the liver and stored in the gallbladder. When food enters the small intestine, the gallbladder releases bile to aid in the digestion of fats. However, this process is not directly related to heartburn during pregnancy.
Choice B rationale
During pregnancy, the body produces large amounts of the hormones progesterone and relaxin. These hormones tend to relax smooth muscle tissues throughout the body, including those in the gastrointestinal (GI) tract. As a result, food sometimes moves more slowly through the system, resulting in indigestion issues of all kinds, from that bloated, gassy feeling to heartburn. This is the correct answer because increased progesterone production does indeed cause decreased motility of smooth muscle, which can lead to heartburn.
Choice C rationale
While estrogen levels do increase during pregnancy, they do not directly cause an increase in the secretion of hydrochloric acid. Instead, the relaxation of the lower esophageal sphincter due to pregnancy hormones can allow stomach acid to flow back up into the esophagus, causing heartburn.
Choice D rationale
While it is true that the growing uterus can displace the stomach, especially in later stages of pregnancy, this is not the primary cause of heartburn. Heartburn is primarily caused by the relaxation of the lower esophageal sphincter, allowing stomach acid to flow back up into the esophagus.
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