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 34 weeks of gestation and is experiencing epigastric pain and headache.

A client who is at 12 weeks of gestation and is experiencing nausea and vomiting.

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 A

Choice A rationale:

The nurse should assess this client first as they are at 34 weeks of gestation and experiencing epigastric pain and headache. These symptoms could be indicative of preeclampsia, a serious pregnancy complication characterized by high blood pressure and organ damage. Preeclampsia requires immediate assessment and intervention to prevent further complications.

Choice B rationale:

Nausea and vomiting are common symptoms during the first trimester of pregnancy, and at 12 weeks of gestation, it is less likely to be a critical issue compared to potential preeclampsia.

Choice C rationale:

Painful urination may indicate a urinary tract infection, which can be important to assess and treat, but it is not as urgent as potential signs of preeclampsia in a client at 34 weeks of gestation.

Choice D rationale:

Cramping and spotting can be normal signs of impending labor, especially at 39 weeks of gestation. While it's important to assess this client, it is not the priority over potential preeclampsia in a client at 34 weeks of gestation with symptoms of epigastric pain and headache.

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Correct Answer is C

Explanation

Choice A rationale:

Scant, bright red spotting during early pregnancy can be a normal finding known as implantation bleeding, which occurs when the embryo attaches to the uterus. It is generally not a cause for concern unless it becomes heavy and is accompanied by severe pain.

Choice B rationale:

Elevated hCG (human chorionic gonadotropin) levels during the first trimester are a normal part of a healthy pregnancy. hCG levels peak around 10-12 weeks of gestation and then gradually decrease. A consistent increase in hCG levels is usually a positive sign of a progressing pregnancy.

Choice C rationale:

Cervical dilation during the first trimester, especially when the client is only at 12 weeks of gestation, is not normal and may indicate an imminent spontaneous abortion (miscarriage). This finding should be reported promptly to the healthcare provider for further assessment and management.

Choice D rationale:

Slight abdominal cramps can be a normal symptom during early pregnancy as the uterus undergoes changes and expands. However, unless they are severe and accompanied by other concerning signs such as heavy bleeding, they are not necessarily indicative of an imminent spontaneous abortion.

A. Fetal bradycardia. B. Decreased ability to bear down. C. Maternal hypertension. D. Uterine hyperstimulation.

Correct Answer is B

Explanation

The correct answer is choiceB. Decreased ability to bear down.

Choice A rationale:

Fetal bradycardia is not a common adverse effect of a pudendal nerve block.This block primarily affects the mother’s pelvic region and does not typically impact fetal heart rate.

Choice B rationale:

Decreased ability to bear down is correct because the pudendal nerve block can numb the perineal area, reducing the mother’s ability to feel contractions and effectively bear down during labor.

Choice C rationale:

Maternal hypertension is not associated with pudendal nerve blocks.This block is localized and does not generally affect systemic blood pressure.

Choice D rationale:

Uterine hyperstimulation is not a known adverse effect of pudendal nerve blocks.This condition is more commonly associated with the use of labor-inducing drugs like oxytocin.

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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

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is at 12 weeks of gestation. The nurse should report which of the following findings to the provider as an indication of an imminent spontaneous abortion?

Correct Answer is C

Explanation

A nurse is caring for a client who has had a pudendal nerve block. The nurse should monitor which of the following findings has an adverse effect.

Correct Answer is B

Explanation

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