As a nurse in an antepartum unit performing triage, which client should be prioritized?

A client who has missed a menstrual cycle and reports vaginal spotting.

A client who is at 28 weeks of gestation and reports painless vaginal bleeding.

A client who is at 38 weeks of gestation and reports symptoms of a cough and fever.

A client who is at 14 weeks of gestation and reports experiencing nausea and vomiting.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Missing a menstrual cycle and reporting vaginal spotting could indicate early pregnancy or other non-emergency conditions. While this client should be evaluated, it is not the highest priority.
Choice B rationale
A client at 28 weeks of gestation reporting painless vaginal bleeding could be experiencing placenta previa or placental abruption, both of which are obstetric emergencies. This client should be prioritized for immediate evaluation.
Choice C rationale
A client at 38 weeks of gestation reporting symptoms of a cough and fever may have an upper respiratory infection. While this should be evaluated, it is not the highest priority unless the client is in distress.
Choice D rationale
Nausea and vomiting are common in early pregnancy. A client at 14 weeks of gestation reporting these symptoms would need evaluation, but it is not the highest priority.

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Correct Answer is B

Explanation

Choice A rationale
While cigarette smoking can increase the risk of many complications during pregnancy, including placental abruption, it is not the most common risk factor. Smoking can cause constriction and damage to the blood vessels in the placenta, but other factors, such as hypertension, are more commonly associated with placental abruption.
Choice B rationale
Hypertension is the most common risk factor for placental abruption. High blood pressure can cause damage to the blood vessels in the placenta, leading to abruption. Chronic hypertension, gestational hypertension, and preeclampsia can all increase a woman’s risk of experiencing a placental abruption.
Choice C rationale
Blunt force trauma, such as that experienced in a car accident or a fall, can cause placental abruption, but it is not the most common risk factor. Any trauma to the abdomen during pregnancy should be evaluated by a healthcare provider to assess for potential complications, including placental abruption.
Choice D rationale
Cocaine use can increase the risk of placental abruption. Cocaine causes intense vasoconstriction, which can compromise the blood flow to the placenta and lead to abruption. However, it is not the most common risk factor for this condition.

A. Increased deposits of fat in the chest and shoulder area. B. Brachial plexus injury. C. Increased blood viscosity. D. Hyperinsulinemia.

Correct Answer is D

Explanation

Choice A rationale
Increased deposits of fat in the chest and shoulder area are not typically associated with respiratory distress syndrome in a newborn. Macrosomic newborns, or those with a high birth weight, may have increased fat deposits, but this is not the primary cause of respiratory distress.
Choice B rationale
A brachial plexus injury is a type of birth injury that can occur due to difficulties during delivery, such as a prolonged labor or a breech presentation. It involves damage to the bundle of nerves that supply the arms and hands. However, it does not directly cause respiratory distress syndrome.
Choice C rationale
Increased blood viscosity could potentially contribute to respiratory distress, but it is not the most likely cause in a macrosomic newborn whose mother has poorly controlled type 2 diabetes. High blood sugar levels in the mother can lead to high insulin levels in the newborn, which is a more direct cause of respiratory distress.
Choice D rationale
Hyperinsulinemia, or high levels of insulin in the blood, is the most likely cause of respiratory distress in this case. When a mother has poorly controlled diabetes, the baby’s pancreas may respond to high glucose levels by producing extra insulin. After birth, the baby may have hypoglycemia (low blood sugar) and increased red blood cell production, both of which can contribute to respiratory distress.

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As a nurse in an antepartum unit performing triage, which client should be prioritized?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a healthcare provider’s office is caring for a patient who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption?

Correct Answer is B

Explanation

A nurse is caring for a term macrosomic newborn whose mother has poorly controlled type 2 diabetes. The newborn has respiratory distress syndrome. The nurse should be aware that the most likely cause of the respiratory distress is which of the following?

Correct Answer is D

Explanation

A nurse is caring for a patient who is in labor at 40 weeks of gestation and reports that she has saturated two perineal pads in the past 30 minutes. The nurse suspects placenta previa. What would be an appropriate nursing action in this situation?

A nurse is caring for a client who is in active labor and notes late decelerations in the FHR. Which of the following actions should the nurse take first?

A nurse is attending to a client in active labor and observes late decelerations on the fetal monitor. What should be the nurse’s priority action?

A nurse is caring for a patient who is about to undergo a biophysical profile. The patient asks the nurse what aspects are evaluated during this test. Which of the following should the nurse include? (Select all that apply)

A nurse midwife is examining a patient who is at 42 weeks of gestation and believes she is in labor. Which of the following findings would confirm to the nurse that the patient is in labor?