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 12 weeks of gestation and is experiencing nausea and vomiting
A client who is at 34 weeks of gestation and is experiencing epigastric pain and headache
A client who is at 38 weeks of gestation and is experiencing painful urination
A client who is at 39 weeks of gestation and is experiencing cramping and spotting
The Correct Answer is B
Among the given options, the client who is at 34 weeks of gestation and experiencing epigastric pain and headache should be assessed first. Epigastric pain and headache can be signs of preeclampsia, a serious condition characterized by high blood pressure and organ dysfunction during pregnancy. Preeclampsia requires immediate attention as it can lead to complications for both the mother and the fetus.
Option a) A client at 12 weeks of gestation experiencing nausea and vomiting may be experiencing normal symptoms of early pregnancy. While it is important to assess the client's well-being, it is not an immediate priority compared to the potential signs of preeclampsia in option b.
Option c) A client at 38 weeks of gestation experiencing painful urination may indicate a urinary tract infection (UTI). While a UTI should be addressed, it does not pose the same level of immediate risk as the potential signs of preeclampsia in option b.
Option d) A client at 39 weeks of gestation experiencing cramping and spotting may be in early labor or have other signs of impending labor. While it is important to assess this client's condition, it is not an immediate priority compared to the potential signs of preeclampsia in option b.
Therefore, the nurse should assess the client who is at 34 weeks of gestation and experiencing epigastric pain and headache as the first priority. Prompt evaluation and management of preeclampsia symptoms are crucial to prevent complications and ensure the well-being of both the mother and the fetus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
These are the findings that place the client at risk for postpartum hemorrhage. Postpartum hemorrhage (PPH) is severe vaginal bleeding after childbirth. It can be a life-threatening condition that requires prompt treatment. The most common cause of PPH is uterine atony, which is when the uterus does not contract enough to stop the bleeding from the placental site¹. Factors that can increase the risk of uterine atony include:
- History of uterine atony: Having a previous episode of PPH due to uterine atony makes it more likely to
happen again in subsequent deliveries.
- Labor induction with oxytocin: Oxytocin is a hormone that stimulates uterine contractions. However, prolonged or excessive use of oxytocin during labor can cause uterine fatigue and reduce its ability to contract after delivery.
- Vacuum-assisted delivery: A vacuum extractor is a device that helps deliver the baby by applying suction to the baby's head. This can cause trauma to the uterus and increase the risk of bleeding.
The other options are not correct because they are not risk factors for postpartum hemorrhage. Let me
explain why:
b) History of human papillomavirus
Human papillomavirus (HPV) is a common sexually transmited infection that can cause genital warts and cervical cancer. However, it does not increase the risk of postpartum hemorrhage. HPV may affect the cervix, but not the uterus or the placenta, which are the main sources of bleeding after delivery³.
c) Newborn weight 2.948 kg (6 Ib 8 oz)
This is a normal newborn weight and does not increase the risk of postpartum hemorrhage. A large baby (more than 4 kg or 8.8 Ib) may increase the risk of uterine atony by overdistending the uterus, but this is not the case for this newborn².
Correct Answer is D
Explanation
This is the only option that is true and relevant to maternal cytomegalovirus infection. CMV can be transmitted from the newborn to the mother or other caregivers through contact with the saliva and urine of the newborn, which may contain high amounts of the virus. Therefore, it is important to practice good hygiene and avoid contact with these body fluids when caring for a newborn with congenital CMV.
a) This infection does not require that airborne precautions be initiated for the newborn. Airborne precautions are used to prevent the spread of infections that are transmitted by small droplets that can remain suspended in the air and travel over long distances, such as tuberculosis, measles, or chickenpox. CMV is not transmitted by airborne route, and standard precautions are sufficient to prevent exposure to blood or body fluids that may contain CMV
b) Mothers will not receive prophylactic treatment with acyclovir prior to delivery. Acyclovir is an antiviral medication that is used to treat herpes simplex virus (HSV) infections, such as cold sores, genital herpes, or neonatal herpes. It has no effect on CMV infection, and it is not recommended for pregnant women or newborns with CMV.
c) Lesions are not visible on the mother's genitals. Lesions are a sign of HSV infection, not CMV infection. HSV can cause painful blisters or ulcers on the mouth or genitals, and it can be transmitted to the newborn during delivery. CMV does not cause any visible symptoms on the mother's genitals, and it can be transmitted to the newborn during pregnancy, delivery, or breastfeeding.
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