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 C
Explanation
Facial petechiae are small, red or purple spots of bleeding under the skin or mucous membranes of the face. They are caused by the rupture of tiny blood vessels called capillaries. Facial petechiae can occur as a result of prolonged straining, such as during childbirth, vomiting, coughing, or crying¹. The increased pressure in the veins of the head and neck can cause the capillaries to burst, resulting in petechiae. Facial petechiae are usually harmless and resolve on their own without treatment.
The other options are not related to prolonged straining and have different causes and appearances:
a) Periauricular papillomas are benign, wart-like growths that occur near the ear. They are caused by human papillomavirus (HPV) infection and may be present at birth or develop later in life. They are usually painless and do not bleed⁴.
b) Erythema toxicum is a common skin condition in newborn babies. It causes a rash and small, fluid-filled bumps that may appear on the face, limbs, or chest. It is not caused by bleeding, infection, or allergy, but by an unknown mechanism. It does not cause discomfort to the baby and clears up without treatment within one to two weeks⁵.
d) Telangiectatic nevi are birthmarks that are caused by dilated blood vessels near the surface of the skin. They appear as red or purple patches or patterns on the skin that do not fade with pressure. They are present at birth and may grow in proportion to the child's growth. They are not associated with bleeding or infection and do not require treatment unless they cause cosmetic concerns⁶.
Correct Answer is D
Explanation
A nonstress test (NST) is a common procedure used to assess the well-being of the fetus. During an NST, the fetal heart rate is monitored for a period of time to evaluate its response to fetal movement. In a normal NST, the fetal heart rate should show accelerations (temporary increases in heart rate) with fetal movement. Lack of accelerations can indicate fetal compromise or a non-reactive test.
In the given scenario, the absence of accelerations for 20 minutes indicates a non-reactive NST. In such cases, further interventions may be required to stimulate the fetus and provoke a response. Vibroacoustic stimulation is a non-invasive method that involves using sound or vibration to stimulate the fetus and elicit a fetal heart rate acceleration. It can be performed by placing a device on the mother's abdomen and delivering a brief sound or vibration near the fetal head.
Option a) Placing the client in the Trendelenburg position is not appropriate in this situation. The Trendelenburg position involves placing the client's head lower than the feet, and it is not indicated for a non-reactive NST.
Option b) Conducting a vaginal exam is not necessary in this scenario. The non-reactive NST indicates a lack of fetal heart rate accelerations, and a vaginal exam would not provide additional information or help in this situation.
Option c) Collecting a specimen for an indirect Coombs test is unrelated to the non-reactive NST. An indirect Coombs test is used to detect antibodies in the mother's blood that could potentially cause hemolytic disease of the newborn. It is not indicated as a response to a non-reactive NST.
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