A nurse is caring for a group of clients on an antepartum unit.
Which of the following clients would be the nurse's priority?
A client admitted for preeclampsia at 34 weeks with a blood pressure of 138/82 mm Hg.
A client admitted for PPROM at 29 weeks with a temperature of 39.1°C (102.3°F).
A client admitted for hyperemesis gravidarum at 18 weeks gestation and reports nausea.
A client admitted for placenta previa at 35 weeks with no vaginal bleeding for the last 12 hours.
The Correct Answer is B
Choice A rationale
Preeclampsia is concerning but the blood pressure of 138/82 mm Hg is not critically high at this moment. Preeclampsia is diagnosed by new-onset hypertension and proteinuria or significant end-organ dysfunction in the latter half of pregnancy. Immediate intervention isn't necessary unless symptoms worsen.
Choice B rationale
PPROM (Preterm Premature Rupture of Membranes) at 29 weeks gestation with a temperature of 39.1°C (102.3°F) suggests a possible infection which can be life-threatening for both the mother and the fetus. Prompt medical attention is critical to manage the infection and prevent sepsis.
Choice C rationale
Hyperemesis gravidarum, while uncomfortable and requiring intervention, is less immediately threatening compared to a severe infection. It involves excessive vomiting leading to dehydration and weight loss but doesn't pose an acute threat as severe infection does.
Choice D rationale
Placenta previa with no vaginal bleeding for the last 12 hours indicates stability. However, any bleeding during pregnancy can be concerning and needs careful monitoring, but immediate intervention is not as crucial as for an infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
Given the symptoms and physical examination findings, the nurse should anticipate a provider prescription for Acyclovir as evidenced by the presence of vesicles and pustules.
The case presented shows several key indicators that point toward a diagnosis of genital herpes, which is caused by the herpes simplex virus (HSV).
- Presence of vesicles and pustules: The small, pinpoint open vesicles and pustules on the labia majora, along with clear drainage, are classic signs of genital herpes.
- Erythema and tenderness: The redness (erythema) and tenderness of the perineal area further support this diagnosis.
- Systemic symptoms: The client reports muscle aches and chills, which are common systemic symptoms of a viral infection like herpes.
- Denies dysuria and other severe symptoms: The absence of symptoms like dysuria and acute distress is consistent with the presentation of genital herpes during the vesicle stage.
Acyclovir is an antiviral medication commonly prescribed for the treatment of herpes simplex infections. It helps to reduce the severity and duration of symptoms. Hence, the nurse should anticipate a prescription for Acyclovir based on the clinical presentation and findings.
Correct Answer is D
Explanation
Choice A rationale
Nausea is typically present in patients with a hydatidiform mole due to high hCG levels.
Choice B rationale
Category II fetal heart rate patterns are indicative of intermediate fetal compromise but are not specific to hydatidiform mole.
Choice C rationale
hCG levels are typically elevated, not decreased, in a hydatidiform mole due to the abnormal growth of trophoblastic tissue.
Choice D rationale
An enlarged uterus is a classic sign of a hydatidiform mole due to the overgrowth of placental tissue without a viable fetus.
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