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
The correct answer is choice C, Ensure the newborn's eyes are closed beneath the shield. Phototherapy is a treatment used to reduce high bilirubin levels in newborns. It involves exposing the newborn's skin to special lights, which helps to break down the excess bilirubin in the blood. It is important to ensure that the newborn's eyes are closed beneath the shield to prevent damage to the eyes from the bright lights. Giving the newborn 1 oz of glucose water every 4 hr, applying lotion to the newborn's skin every 8 hr, and dressing the newborn in a thin layer of clothing during therapy are not indicated interventions during phototherapy.
Correct Answer is D
Explanation
The correct answer is choice D, Sharp pelvic pain. An ectopic pregnancy occurs when a fertilized egg implants outside of the uterus, most commonly in the fallopian tube. Sharp pelvic pain is a classic sign of an ectopic pregnancy, as the developing embryo can cause the tube to rupture or stretch, leading to pain. A scaphoid abdomen, elevated blood pressure, and bright red vaginal discharge are not typical manifestations of an ectopic pregnancy. 
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