A nurse in the emergency department is caring for a group of clients.
Which of the following clients should the nurse plan to see first?
A client who is at 6 weeks of gestation with severe abdominal pain, no bleeding, a blood pressure of 86/58 mm Hg and a pulse of 132/min.
A client who has an ectopic pregnancy, a blood pressure of 128/84 mm Hg a pulse of 88/min, and is crying.
A client who is at 9 weeks of gestation, took one dose of methotrexate and is now reporting moderate pain and dizziness, has a blood pressure of 116/80 mm Hg and a pulse of 86/min.
A client who is at 8 weeks of gestation with moderate vaginal bleeding, has minimal abdominal pain, a blood pressure of 118/72 mm Hg and a pulse of 96/min.
The Correct Answer is A
Choice A rationale
The client at 6 weeks gestation exhibiting severe abdominal pain, hypotension (86/58 mm Hg), and tachycardia (132/min) suggests a potential ruptured ectopic pregnancy or other acute abdominal emergency requiring immediate intervention. Hypotension indicates inadequate tissue perfusion, and tachycardia is a compensatory mechanism to maintain cardiac output. Severe pain further indicates an acute process that necessitates prompt assessment and treatment to prevent further hemodynamic instability and potential life-threatening complications.
Choice B rationale
While a client with an ectopic pregnancy requires monitoring and care, the vital signs reported (blood pressure 128/84 mm Hg, pulse 88/min) are within normal limits. Normal blood pressure ranges are typically systolic 90-120 mm Hg and diastolic 60-80 mm Hg, and a normal pulse rate is generally 60-100 beats per minute. Although emotional distress from the diagnosis is important, the physiological parameters do not indicate an immediate critical threat compared to the client in Choice A.
Choice C rationale
A client at 9 weeks gestation who received methotrexate for an ectopic pregnancy and reports moderate pain and dizziness with stable vital signs (blood pressure 116/80 mm Hg, pulse 86/min) requires assessment for expected side effects of the medication or signs of treatment failure. Methotrexate can cause abdominal pain as it works to dissolve the pregnancy. While monitoring is necessary, the stable vital signs do not suggest an immediate life-threatening emergency compared to the client in Choice A.
Choice D rationale
A client at 8 weeks gestation with moderate vaginal bleeding, minimal abdominal pain, and stable vital signs (blood pressure 118/72 mm Hg, pulse 96/min) may be experiencing a threatened or inevitable miscarriage. While vaginal bleeding in early pregnancy warrants investigation and monitoring, the stable vital signs and minimal pain do not indicate an immediate critical emergency requiring prioritization over the client in Choice A who presents with signs of hemodynamic instability. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B"]
Explanation
Choice A rationale
Ectopic pregnancy occurs when a fertilized egg implants outside the uterus, most commonly in the fallopian tube. Symptoms can include unilateral abdominal pain, light to heavy vaginal bleeding, and a positive pregnancy test. An ectopic pregnancy is a serious condition requiring prompt medical attention.
Choice B rationale
Molar pregnancy, also known as gestational trophoblastic disease, is characterized by abnormal growth of trophoblasts, the cells that normally develop into the placenta. It can present with symptoms such as vaginal bleeding (ranging from spotting to heavy bleeding), pelvic pain or pressure, and a uterus that may be larger than expected for the gestational age. The absence of a fetal heartbeat and elevated hCG levels are also characteristic.
Correct Answer is D
Explanation
Choice A rationale
While understanding methods of labor induction is important if the pregnancy progresses to 42 weeks, it is not the priority teaching at 31 weeks gestation. The immediate focus should be on recognizing potential complications that could arise before the scheduled induction.
Choice B rationale
The benefits of breastfeeding are important for all pregnant women but are not the priority teaching for a client at 31 weeks who is not yet in labor. Information about breastfeeding can be provided later in the pregnancy.
Choice C rationale
Teaching the signs of labor is important as the client approaches term, but at 31 weeks, the priority is to educate the client on recognizing potential warning signs that require immediate attention, such as decreased fetal movement.
Choice D rationale
Monitoring fetal movement is a crucial teaching point at 31 weeks gestation. A decrease in fetal movement can be an early indicator of fetal compromise and requires prompt evaluation. Instructing the client on how to perform kick counts and when to report changes is a priority for ensuring fetal well-being before the scheduled induction.
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