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 A

Explanation

Uterine rupture is a rare but life-threatening complication of labor and delivery that occurs when the uterus tears open along the scar line of a previous cesarean delivery or other uterine surgery¹². Uterine rupture can cause severe bleeding in the mother and deprive the baby of oxygen¹². Some of the signs and symptoms of uterine rupture are:
- Sudden, severe lower abdominal pain
- Drop in blood pressure
- Cool skin and pallor
- Prolonged fetal bradycardia (slow heart rate)
- Loss of fetal station (the baby moves back up the birth canal)
- Abnormal or absent uterine contractions¹²³

Uterine rupture is a medical emergency that requires immediate surgery to deliver the baby and repair the uterus or remove it (hysterectomy)¹².
The other options are incorrect because they have diﬀerent signs and symptoms:
b) Amniotic ﬂuid embolism is a rare but serious condition that occurs when amniotic ﬂuid or fetal cells enter the mother's bloodstream and trigger an allergic reaction. It can cause sudden respiratory distress, cardiac arrest, seizures, or coma in the mother and fetal distress or death in the baby¹². It usually occurs during labor, delivery, or shortly after birth¹².
c) Placenta previa is a condition where the placenta covers part or all of the opening of the cervix. It can cause painless vaginal bleeding during pregnancy or labor¹². It does not aﬀect the blood pressure or fetal heart rate unless there is severe bleeding or placental abruption (separation of the placenta from the uterine wall)¹².
d) Umbilical cord prolapse is a condition where the umbilical cord slips through the cervix and into the vagina before or during labor. It can cause fetal distress, as the cord can become compressed or twisted, cutting oﬀ the blood supply and oxygen to the baby¹². It usually causes a sudden drop in fetal heart rate, but does not aﬀect the maternal blood pressure or cause abdominal pain¹².

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?

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Correct Answer is A

Explanation

A nurse is planning care for a newborn who is scheduled to start phototherapy using a lamp. Which of the following actions should the nurse include in the plan?

Correct Answer is C

Explanation

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