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 B
Explanation
Choice A rationale
While infection prevention is vital, ensuring breathing function is more critical after ASP.
Choice B rationale
ASP affects the respiratory system severely; thus, restoring normal breathing is a primary goal.
Choice C rationale
Gastrointestinal function is less immediately affected by ASP compared to respiratory issues.
Choice D rationale
Voiding without pain is important, but respiratory stability takes precedence.
Correct Answer is A
Explanation
Choice A rationale
Postpartum psychosis poses significant risks to both the mother and her infant. The mother may have impaired judgment, hallucinations, or delusions, making it unsafe for her to be
left alone with her baby.
Choice B rationale
Symptoms of postpartum psychosis can persist for several weeks to months without appropriate treatment. Immediate and ongoing intervention is crucial to manage the condition.
Choice C rationale
Clinical response to medications for postpartum psychosis can vary, but with proper treatment, many clients show significant improvement. It is not accurate to state that the
response is usually poor.
Choice D rationale
While monitoring vitals may be part of overall care, it is not the most critical teaching point. Ensuring the mother is never left alone with her infant is essential to prevent potential
harm.