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The antepartum nurse has just received shift report on four pregnant clients at 0700.
Which of the clients should the nurse assess first?

A.

G5 P2202, 32 weeks, placenta previa, today's hemoglobin 11.6 g/dL.

B.

G2 P0101, 39 weeks, type 2 diabetes mellitus (T2DM), fasting blood glucose.

C.

G1 P0000, 32 weeks, partial placental abruption, fetal heart rate (FHR) 120 bpm 15 minutes ago.

D.

G2 P1001, 28 weeks, Rh-negative (Rh-), 1 day post cerclage placement.

Answer and Explanation

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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View Related questions

Correct Answer is ["A","B","D"]

Explanation

Choice A rationale

Petechiae, small red or purple spots on the skin, indicate a low platelet count, which is a component of HELLP syndrome.

Choice B rationale

Jaundice, a yellowing of the skin and eyes, suggests liver involvement and hemolysis, both of which are features of HELLP syndrome.

Choice C rationale

4+ deep tendon reflexes are associated with severe pre-eclampsia but are not specific to HELLP syndrome.

Choice D rationale

3+ pitting edema, severe fluid retention causing swelling, can be a sign of HELLP syndrome, indicating liver or kidney involvement. .

Correct Answer is C

Explanation

Choice A rationale

Magnesium sulfate is primarily used for neuroprotection in preterm infants and to prevent seizures in severe preeclampsia, not as a first-line tocolytic for preterm labor.

Choice B rationale

Morphine sulfate is an opioid analgesic used for pain management, not for inhibiting preterm labor contractions.

Choice C rationale

Terbutaline is a beta-agonist used as a tocolytic to relax uterine muscles and delay preterm labor. It helps decrease the intensity and frequency of contractions, making it suitable for managing preterm labor.

Choice D rationale

Betamethasone is a corticosteroid used to accelerate fetal lung maturity in preterm labor, not for direct contraction inhibition.

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