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 B
Explanation
Choice A rationale
Hypotonic uterine dysfunction typically occurs in the active phase of labor (after 4 cm cervical dilation) and is characterized by weak, infrequent, and ineffective contractions that do not lead to cervical change. The client in the latent phase with slow cervical change is not yet in the active phase.
Choice B rationale
The latent phase of the first stage of labor is characterized by irregular, mild to moderate contractions that cause slow, gradual cervical dilation and effacement. It can be lengthy, especially in primigravidas, and the discomfort can be significant. A cervical dilation of 2 cm with no change in 3 hours in the presence of painful, erratic contractions every 5 to 10 minutes aligns with a normal latent phase.
Choice C rationale
Hypertonic uterine dysfunction usually occurs in the latent phase and is characterized by frequent, uncoordinated, and strong contractions that are ineffective in causing cervical dilation or effacement. While the contractions are painful, they are not described as excessively strong or uncoordinated, and the client is in the expected early stage of labor.
Choice D rationale
Precipitous labor is a very rapid labor and delivery, typically lasting less than 3 hours from the onset of regular contractions to expulsion of the fetus. The client's labor is progressing slowly, with minimal cervical change over 3 hours, which is the opposite of precipitous labor.
Correct Answer is A
Explanation
Choice A rationale
G represents gravida, the total number of pregnancies, including the current one (2). T represents term births, the number of pregnancies delivered at 37 weeks gestation or later (1). P represents preterm births, the number of pregnancies delivered between 20 and 36 weeks gestation (0). A represents abortions, the number of pregnancies ending before 20 weeks gestation (0). L represents living children (1).
Choice B rationale
This option incorrectly states L as 2. The client has one living child from the previous pregnancy.
Choice C rationale
This option incorrectly states P as 1. The client's previous pregnancy was delivered at 38 weeks, which is considered a term birth, not preterm.
Choice D rationale
This option incorrectly states G as 3. The client is currently pregnant with twins, making this her second pregnancy in total.
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