A nurse receives a shift report and must first assess the high-risk antenatal client who is:
35 weeks gestation with proteinuria and vomiting.
39 weeks gestation with urinary urgency, frequency, and burning.
30 weeks gestation with a fasting blood sugar of 95 mg/dL and a 3-hour glucose of 120.
34 weeks gestation with a hemoglobin of 12 mg/dL and a potassium level of 3.5 mEq/L. .
The Correct Answer is A
Choice A rationale
Proteinuria and vomiting at 35 weeks gestation are significant symptoms that could indicate preeclampsia, a serious condition that requires immediate assessment and management to prevent complications for both the mother and the baby.
Choice B rationale
Urinary urgency, frequency, and burning at 39 weeks gestation suggest a possible urinary tract infection (UTI), which is concerning but generally not as immediately critical as symptoms suggesting preeclampsia.
Choice C rationale
A fasting blood sugar of 95 mg/dL and a 3-hour glucose of 120 at 30 weeks gestation indicate good control of blood sugar levels, which is not as high-risk as preeclampsia symptoms.
Choice D rationale
A hemoglobin of 12 mg/dL and a potassium level of 3.5 mEq/L at 34 weeks gestation are within normal ranges and do not indicate an immediate high-risk condition compared to the potential for preeclampsia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Observing the perineum for signs of crowning is important, but it doesn’t address the immediate need to manage the client’s urge to push. By the time crowning is visible, delivery is imminent, and the urge to push should have been managed earlier.
Choice B rationale
Helping the client to the bathroom to void might relieve some pressure but is not the immediate priority when the client feels the urge to push. Voiding can wait until contractions are managed.
Choice C rationale
Assisting the client into a supine position is not ideal for managing the urge to push. A supine position can increase discomfort and does not facilitate optimal delivery dynamics.
Choice D rationale
Assisting the client with quick shallow breathing helps manage the urge to push and prevents premature pushing, reducing the risk of cervical injury and aiding controlled delivery.
Correct Answer is D
Explanation
A. Administer Rh immunoglobulin (Rho(D) immune globulin): This is important if the mother is Rh-negative, but there is no indication of Rh incompatibility in this scenario.
B. Perform continuous fetal heart rate monitoring: This is essential for ongoing assessment of fetal well-being but may not be the very first immediate action.
C. Prepare for emergent delivery: This would only be necessary if there were signs of fetal or maternal distress, which are not currently indicated.
D. Administer a corticosteroid to enhance fetal lung maturity: Administering corticosteroids like betamethasone or dexamethasone is crucial between 24 and 34 weeks of gestation to enhance lung maturity and reduce the risk of neonatal respiratory distress syndrome.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.