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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Group B Streptococcus β-hemolytic (GBS) is a type of bacteria that can cause serious infections in newborns, such as sepsis, pneumonia, and meningitis. GBS can be transmitted from the mother to the baby during labor and delivery if the mother is colonized with GBS in her vagina or rectum¹.
To prevent GBS infection in newborns, pregnant women who test positive for GBS or have risk factors for GBS should receive intravenous (IV) antibiotics during labor. The antibiotics can reduce the amount of GBS bacteria in the mother's body and lower the chance of passing them to the baby¹².
The recommended antibiotic for GBS prophylaxis is penicillin, which is safe and eﬀective for most women. However, some women may be allergic to penicillin and need an alternative antibiotic. Ampicillin is one of the alternative antibiotics that can be used for GBS prophylaxis in women who have a mild allergy to penicillin (such as rash or itching). Ampicillin is also a type of penicillin, but it has a slightly diﬀerent structure and may not cause an allergic reaction in some people²³.
Therefore, the nurse should plan to administer ampicillin to the client who tested positive for GBS and has a mild allergy to penicillin. The nurse should also monitor the client for any signs of anaphylaxis (a severe allergic reaction) and have epinephrine ready in case of emergency²³.

The other options are not medications that the nurse should administer to the client:
- a) Cefotetan is another alternative antibiotic that can be used for GBS prophylaxis in women who have a severe allergy to penicillin (such as anaphylaxis or angioedema). However, it is not indicated for women who have a mild allergy to penicillin, as it may still cause cross-reactivity and an allergic reaction²³.
- b) Fluconazole is an antifungal medication that is used to treat fungal infections, such as candidiasis (thrush) or cryptococcal meningitis. It is not eﬀective against bacterial infections, such as GBS, and it is not indicated for GBS prophylaxis⁴.
- d) Doxycycline is an antibiotic that is used to treat bacterial infections, such as chlamydia, gonorrhea, or Lyme disease. It is not eﬀective against GBS and it is not indicated for GBS prophylaxis. Moreover, doxycycline is contraindicated in pregnancy, as it can cause harm to the fetus, such as tooth discoloration or bone growth problems.

A. Give the newborn 1 oz of glucose water every 4 hours. B. Apply a thin layer of lotion to the newborn's skin every 8 hours. C. Ensure the newborn's eyes are closed beneath the shield. D. Dress the newborn in a thin layer of clothing during therapy.

Correct Answer is C

Explanation

Phototherapy is a treatment method used to reduce high levels of bilirubin in the blood of a newborn with jaundice. During phototherapy, the newborn is exposed to special lights that help break down the bilirubin and allow it to be eliminated from the body. It is important to protect the newborn's eyes during phototherapy.

Option a) Giving the newborn 1 oz of glucose water every 4 hours is not necessary for phototherapy. The primary goal of phototherapy is to treat jaundice, and providing glucose water is not directly related to this treatment.

Option b)Applying a thin layer of lotion to the newborn's skin every 8 hours is not necessary during phototherapy. In fact, it is generally recommended to avoid applying lotions or oils to the skin during phototherapy as they can interfere with the eﬀectiveness of the treatment.

Option c) Ensuring the newborn's eyes are closed beneath the shield is essential during phototherapy. The eyes are particularly sensitive to the light used in phototherapy, and exposure to the light can potentially damage the eyes. Therefore, the newborn's eyes should be protected with a shield or eye patches to prevent direct exposure to the light.

Option d) Dressing the newborn in a thin layer of clothing during therapy is appropriate. The newborn should be dressed in a way that allows as much of their skin as possible to be exposed to the phototherapy lights. This usually involves removing unnecessary clothing and covering the genital area with a diaper, while the rest of the body is exposed to the light.

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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?

Nursing Test Bank

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Explanation

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Correct Answer is C

Explanation

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