A nurse on an antepartum unit is receiving change-of-shift report for four clients. Which of the following clients should the nurse assess first?
A client who is at 38 weeks of gestation and is experiencing painful urination
A client who is at 34 weeks of gestation and is experiencing epigastric pain and headache
A client who is at 12 weeks of gestation and is experiencing nausea and vomiting
A client who is at 39 weeks of gestation and is experiencing cramping and spotting
The Correct Answer is B
The client who is at 34 weeks of gestation and is experiencing epigastric pain and headache should be assessed first. These symptoms may indicate preeclampsia, which is a serious pregnancy complication characterized by high blood pressure and organ damage. The nurse should monitor the client's blood pressure and assess for signs of organ damage, such as proteinuria, visual disturbances, and epigastric or right upper quadrant pain. The other clients may also require assessment and intervention, but their symptoms are less urgent and may indicate less serious conditions, such as a urinary tract infection (painful urination), early pregnancy symptoms (nausea and vomiting), or early labor (cramping and spotting).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Discomfort in the lower back (sacral area) is common during labor, particularly during contractions. This is not an unusual finding that would require immediate reassessment.
B. Contractions lasting between 45 to 60 seconds are typical during the active phase of labor. This duration of contractions is expected as labor progresses, and does not require immediate reassessment.
C. This sensation can indicate that the fetus has descended into the birth canal and may be a sign that the client is entering the second stage of labor, or is close to delivery. This requires immediate reassessment by the nurse to check for full cervical dilation and fetal descent.
D. Emotional excitement and changes in skin temperature are typical responses during labor due to the physiological and emotional aspects of childbirth. This does not indicate the need for immediate reassessment.
Correct Answer is C
Explanation
"You can expect your breasts to be firm and tender 3 to 5 days after delivery." Postpartum care includes education on physical changes that occur after delivery. It is important for the nurse to inform the client that breast engorgement is a common occurrence and may result in firm, tender breasts 3 to 5 days after delivery. The nurse should also encourage the client to use a breast pump or express milk by hand to relieve discomfort. It is not advisable for the client to rely solely on breastfeeding as a form of birth control, so the nurse should educate the client on the importance of using contraception. Postpartum bleeding is typically bright red
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.