The antepartum nurse has just received shift report on four pregnant clients at 0700.
Which of the clients should the nurse assess first?
G5 P2202, 32 weeks, placenta previa, today's hemoglobin 11.6 g/dL.
G2 P0101, 39 weeks, type 2 diabetes mellitus (T2DM), fasting blood glucose.
G1 P0000, 32 weeks, partial placental abruption, fetal heart rate (FHR) 120 bpm 15 minutes ago.
G2 P1001, 28 weeks, Rh-negative (Rh-), 1 day post cerclage placement.
The Correct Answer is C
Choice A rationale
The hemoglobin level of 11.6 g/dL is within the normal range for a pregnant woman. While placenta previa requires monitoring, it is not immediately life-threatening.
Choice B rationale
Type 2 diabetes mellitus requires regular monitoring and management, but a single fasting blood glucose level does not indicate an immediate emergency unless it is extremely high or low.
Choice C rationale
Partial placental abruption can lead to significant complications for both the mother and fetus, including hemorrhage and fetal distress, making it the priority for immediate assessment.
Choice D rationale
An Rh-negative status and a recent cerclage placement are important for ongoing monitoring but do not present an immediate life-threatening condition that demands the first assessment.
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Correct Answer is D
Explanation
Choice A rationale
Bleeding is typically not associated with a vaginal hematoma; it is more indicative of other postpartum complications such as uterine atony or retained placenta fragments.
Choice B rationale
Warmth is usually associated with infection or inflammation. A hematoma is a collection of clotted blood outside the blood vessels, not typically characterized by warmth.
Choice C rationale
Redness might be seen in cases of infection or inflammation. A vaginal hematoma is a localized collection of blood and does not inherently cause redness.
Choice D rationale
Pain is a common symptom of a vaginal hematoma due to the pressure and swelling from the accumulated blood.
Correct Answer is D
Explanation
Choice A rationale
Placental abruption involves the detachment of the placenta from the uterine wall before delivery, causing bleeding, abdominal pain, and uterine tenderness. It does not typically cause dyspnea, hypotension, frothy sputum, or loss of consciousness.
Choice B rationale
Uterine rupture is a tear in the uterine wall, often in a scarred uterus. Symptoms include severe abdominal pain, abnormal fetal heart rate, and vaginal bleeding. It can cause shock, but not frothy sputum or sudden dyspnea.
Choice C rationale
Uterine inversion occurs when the uterus turns inside out, often during placental delivery. It leads to pain, hemorrhage, and shock. Like uterine rupture, it does not cause frothy sputum or sudden dyspnea.
Choice D rationale
Anaphylactoid syndrome (amniotic fluid embolism) occurs when amniotic fluid enters the maternal circulation, causing an anaphylactic reaction. Symptoms include sudden dyspnea, hypotension, frothy sputum, and loss of consciousness, fitting the scenario described.