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 D
Explanation
Hemolytic disease of the newborn (HDN) is a condition that occurs when there is an incompatibility between the blood types of the mother and the baby. It causes the mother's immune system to produce antibodies that attack and destroy the baby's red blood cells, leading to anemia, jaundice, organ enlargement, and other complications¹.
One of the most common causes of HDN is Rh incompatibility. This happens when the mother is Rh negative and the baby is Rh positive. The Rh factor is a protein that can be present or absent on the surface of red blood cells. People who have the protein are Rh positive and people who do not have it are Rh negative
Rh incompatibility can cause HDN when the baby's Rh positive blood cells cross the placenta and enter the mother's bloodstream. This can happen during delivery, miscarriage, abortion, or invasive prenatal testing. The mother's immune system recognizes the baby's blood cells as foreign and produces antibodies against them. These antibodies can cross back to the baby's bloodstream and attack the baby's red blood cells, causing hemolysis (breakdown) and anemia².
HDN due to Rh incompatibility usually does not affect the first pregnancy, because the mother has not been exposed to Rh positive blood before and has not developed antibodies yet. However, it can affect subsequent pregnancies with Rh positive babies, because the mother has become sensitized and has antibodies ready to attack².
The other options are not causes of HDN:
a) The mother and the father are both Rh negative. This is not a cause of HDN because both parents have the same Rh factor and there is no incompatibility between them. The baby will also be Rh negative and will not trigger an immune response from the mother².
b) The mother and the father are both Rh positive. This is not a cause of HDN because both parents have the same Rh factor and there is no incompatibility between them. The baby will also be Rh positive and will not trigger an immune response from the mother².
c) The mother is Rh positive and the father is Rh negative. This is not a cause of HDN because the mother has a dominant Rh factor and will not produce antibodies against it. The baby will either be Rh positive or Rh negative, depending on whether they inherit the father's gene or not. In either case, the baby's blood type will not trigger an immune response from the mother².
Correct Answer is C
Explanation
Ultrasonography is a diagnostic imaging technique that uses high-frequency sound waves to create images of the internal structures of the body. It is a safe and noninvasive method that can provide valuable information about the pregnancy, such as the number, size, location, and health of the fetus(es), the placenta, the amniotic fluid, and the uterus.
Ultrasonography can be performed at any time during pregnancy, but it is especially useful in the first trimester (the first 12 weeks of pregnancy) for several reasons, such as:
- To confirm the pregnancy and rule out ectopic pregnancy (a pregnancy that occurs outside the uterus) or molar pregnancy (a pregnancy that develops into an abnormal mass of tissue)
- To determine gestational age (the length of time since the first day of the last menstrual period) and estimate due date (the expected date of delivery)
- To screen for chromosomal abnormalities (such as Down syndrome) or structural defects (such as spina bifida) in the fetus
- To identify multiple gestations (such as twins or triplets) or complications (such as miscarriage or
bleeding)
One of the main uses of ultrasonography in the first trimester is to determine gestational age. This is important because it can affect many aspects of prenatal care and delivery, such as:
- The timing and accuracy of other tests and procedures
- The monitoring and evaluation of fetal growth and development
- The identification and management of potential problems or complications
- The planning and preparation for labor and delivery
Gestational age can be determined by measuring the crown-rump length (CRL) of the fetus, which is the distance from the top of the head to the bottom of the spine. The CRL can be measured by using a transvaginal ultrasound (an ultrasound probe that is inserted into the vagina) or a transabdominal ultrasound (an ultrasound probe that is moved over the abdomen). The CRL can be compared to a standard growth chart to estimate gestational age. The CRL measurement is most accurate between 7 and 13 weeks of pregnancy .
Therefore, the newly licensed nurse who says that ultrasound is used to determine gestational age in the first trimester indicates an understanding of the teaching.
The other statements show a lack of knowledge or misunderstanding of the uses of ultrasonography in the first trimester:
- a) "Ultrasound is used to observe for placental maturity in the first trimester." This is not correct because placental maturity is not assessed in the first trimester. Placental maturity refers to the changes that occur in the placenta as it ages and prepares for delivery. Placental maturity can be evaluated by using a grading system that ranges from 0 to 3, based on the appearance of calcifications (deposits of calcium) in the placenta. Placental maturity can be assessed by using a transabdominal ultrasound in the third trimester (after 28 weeks of pregnancy).
- b) "Ultrasound is used to detect intrauterine growth restriction in the first trimester." This is not correct because intrauterine growth restriction (IUGR) is not detected in the first trimester. IUGR is a condition in which the fetus does not grow as expected and has a low birth weight for its gestational age. IUGR can be caused by various factors, such as placental insufficiency, maternal malnutrition, infection, or chronic disease. IUGR can affect fetal development and increase the risk of complications, such as hypoxia, hypoglycemia, or stillbirth. IUGR can be diagnosed by measuring fetal growth parameters, such as abdominal circumference, head circumference, femur length, and estimated fetal weight. These measurements can be obtained by using a transabdominal ultrasound in the second or third trimester (after 20 weeks of pregnancy).
- d) "Ultrasound is used to perform a biophysical profile in the first trimester." This is not correct because a biophysical profile (BPP) is not performed in the first trimester. A BPP is a test that evaluates fetal well-being by assessing five parameters: fetal movement, fetal tone, fetal breathing, amniotic fluid volume, and fetal heart rate. A BPP can help detect fetal distress or hypoxia and guide management decisions. A BPP can be performed by using a combination of transabdominal ultrasound and nonstress test (NST) in the third trimester (after 32 weeks of pregnancy).
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