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 B
Explanation
Choice A rationale
Calcium gluconate is the antidote for magnesium sulfate toxicity but is administered after stopping the infusion.
Choice B rationale
The first action is to stop the magnesium sulfate infusion to prevent further respiratory depression and absent reflexes.
Choice C rationale
Preparing for an urgent cesarean birth is not the immediate first action for treating magnesium sulfate toxicity.
Choice D rationale
Administering IV fluid bolus does not address the immediate issue of magnesium sulfate toxicity. .
Correct Answer is A
Explanation
Choice A rationale
CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel), Urinalysis, and Clotting studies are crucial tests in this scenario. Headache, edema of the face, and right upper quadrant abdominal pain in a pregnant client at 37 weeks gestation are concerning for preeclampsia or HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelet count). CBC can help detect hemolysis and thrombocytopenia, CMP can evaluate liver function, Urinalysis can check for proteinuria indicative of preeclampsia, and Clotting studies assess coagulation status, which is vital for detecting any disseminated intravascular coagulation (DIC) complications.
Choice B rationale
HgA1C is a test used to monitor long-term glucose control in clients with diabetes. Although it provides valuable information regarding glucose levels over the past 2-3 months, it is not relevant in the immediate assessment of acute symptoms like headache, edema, and abdominal pain in the context of preeclampsia or HELLP syndrome.
Choice C rationale
Abdominal ultrasound can be used to assess fetal well-being and placental function, but it does not directly address the immediate concerns associated with preeclampsia or HELLP syndrome. It can be a supportive diagnostic tool but not the primary assessment in this acute scenario.
Choice D rationale
CBC, Amylase, Lipase, and Bile acids are tests typically used to evaluate for pancreatitis or liver disease. While CBC is relevant, the inclusion of Amylase, Lipase, and Bile acids does not directly correlate with the specific symptoms of headache, edema, and right upper quadrant pain associated with preeclampsia or HELLP syndrome. Thus, this combination is not the most appropriate set of diagnostic tests for the client's condition. .
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