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 A

Explanation

Step 1 is to calculate the volume of Toradol to be drawn up. Toradol is available in 60 mg/mL. Therefore, to administer a dose of 30 mg, the nurse would need to draw up 30 mg ÷ 60 mg/mL = 0.5 mL.

A. Hypomagnesemia B. Hyperbilirubinemia C. Hypocalcemia D. Hypoglycemia

Correct Answer is D

Explanation

Choice A rationale
Hypomagnesemia, or low magnesium levels, is not typically a primary concern for newborns of mothers with diabetes mellitus. While it can occur, it is not the priority focus of care.
Choice B rationale
Hyperbilirubinemia, or high bilirubin levels, can lead to jaundice in newborns. However, it is not the primary concern in newborns of mothers with diabetes mellitus. These newborns are more at risk for hypoglycemia.
Choice C rationale
Hypocalcemia, or low calcium levels, can occur in newborns, but it is not the primary concern in newborns of mothers with diabetes mellitus. These newborns are more at risk for hypoglycemia.

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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

Three hours post cesarean section, the physician orders Toradol 30 mg IM every 6 hours for pain. Toradol is available in 60 mg/mL. How many mLs should be drawn up?

Correct Answer is A

Explanation

A nurse is caring for a newborn who has macrosomia and whose mother has diabetes mellitus. Which of the following newborn complications should the nurse recognize as the priority focus of care?

Correct Answer is D

Explanation

A nurse is monitoring a patient who is receiving magnesium sulfate to manage pre-eclampsia. Which of the following observations should the nurse report to the healthcare provider?

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 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?

A nurse is preparing an in-service program about preventing medication errors when transcribing a prescription. The nurse is using a dosage example of two tenths of a milligram. Which of the following examples should the nurse use to show appropriate transcription of this dosage?

A nurse is caring for a client who is 39 weeks pregnant and in active labor. The nurse detects the fetal heart tones above the client’s umbilicus at the midline. Which of the following positions should the nurse suspect the fetus is in?

A nurse is caring for a client who is at 36 weeks of gestation and suspected of having placenta previa. Which of the following symptoms would support this diagnosis?