Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse in an antepartum unit is triaging clients. Which of the following clients should the nurse see first?
A. A client who is at 38 weeks of gestation and reports a cough and fever.
A client who is at 38 weeks of gestation and reports a cough and fever: This client should be seen first as cough and fever can be indicative of an infection, which poses a potential risk to both the mother and the unborn baby. It may indicate respiratory issues like pneumonia or other infections, which require immediate assessment and treatment.
B. A client who has missed a period and reports vaginal spotting.
A client who has missed a period and reports vaginal spotting: While this client requires assessment, it is not as urgent as the one with potential infection symptoms. Vaginal spotting during early pregnancy can be normal, but it should still be evaluated to rule out any concerns.
C. A client who is at 14 weeks of gestation and reports nausea and vomiting.
A client who is at 14 weeks of gestation and reports nausea and vomiting: Nausea and vomiting can be common during early pregnancy, especially around 14 weeks. While it is essential to address the client's concerns, it is not an immediate emergency.
D. A client who is at 28 weeks of gestation and reports painless vaginal bleeding.
A client who is at 28 weeks of gestation and reports painless vaginal bleeding: Painless vaginal bleeding at 28 weeks should not be ignored, but it is not as urgent as the client with cough and fever, which may indicate an infection.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Maternity Exam - Proctored Exam 2. Take the full exam now
Full Explanation
A. A client at 38 weeks of gestation with a cough and fever may have an infection, which is concerning, but it is not immediately life-threatening. The nurse should assess this client soon, but it is not the highest priority.
B. A client who has missed a period and reports vaginal spotting could be experiencing an early pregnancy complication, such as a miscarriage or ectopic pregnancy. This situation requires attention, but it is not as urgent as painless vaginal bleeding in the third trimester.
C. A client at 14 weeks of gestation with nausea and vomiting is likely experiencing common pregnancy symptoms. While these symptoms can be uncomfortable and require management, they are not typically urgent.
D. A client at 28 weeks of gestation with painless vaginal bleeding could be experiencing placenta previa or another serious condition that poses an immediate risk to both the mother and the fetus. This situation requires urgent assessment and intervention.
Similar Questions
A nurse is assessing a client in labor who has had epidural anesthesia for pain relief. Which of the following findings should the nurse identify as a complication from the epidural block?
A. Vomiting
Vomiting: Vomiting is not a common complication of epidural anesthesia. Nausea can occur but is not directly related to the epidural block itself.
B. Tachycardia
Tachycardia: Tachycardia is not a common complication of epidural anesthesia. It may occur due to other factors, but it is not directly associated with the epidural block.
C. Hypotension
Hypotension: Hypotension (low blood pressure) is a common complication of epidural anesthesia. The epidural can cause vasodilation, leading to a drop in blood pressure. It is essential to monitor the client's blood pressure and intervene promptly if hypotension occurs.
D. Respiratory depression
Respiratory depression: Respiratory depression is not a typical complication of epidural anesthesia. Epidural anesthesia mainly affects the lower part of the body and does not usually cause significant respiratory effects.
Full Explanation
A) Vomiting: Vomiting is not a common complication of epidural anesthesia. Nausea can occur but is not directly related to the epidural block itself.
B) Tachycardia: Tachycardia is not a common complication of epidural anesthesia. It may occur due to other factors, but it is not directly associated with the epidural block.
C) Hypotension: Hypotension (low blood pressure) is a common complication of epidural anesthesia. The epidural can cause vasodilation, leading to a drop in blood pressure. It is essential to monitor the client's blood pressure and intervene promptly if hypotension occurs.
D) Respiratory depression: Respiratory depression is not a typical complication of epidural anesthesia. Epidural anesthesia mainly affects the lower part of the body and does not usually cause significant respiratory effects.
A nurse in the labor and delivery unit is caring for a client who is undergoing external fetal monitoring. The nurse observes that the fetal heart rate begins to slow after the start of a contraction and the lowest rate occurs after the peak of the contraction. Which of the following actions should the nurse take first?
A. Administer oxygen using a nonrebreather mask.
Administer oxygen using a nonrebreather mask: While oxygen may be necessary if there are signs of fetal distress, the priority action in this situation is to reposition the client and relieve potential cord compression.
B. Elevate the client's legs.
Elevate the client's legs: Elevating the client's legs is not the most appropriate action in this situation and may not address the cause of the decelerations.
C. Place the client in the lateral position.
Place the client in the lateral position: This is the correct answer. The described pattern of the fetal heart rate (slowdown after the start of a contraction with the lowest rate occurring after the peak of the contraction) suggests late decelerations, which are often caused by uteroplacentalinsufficiency or cord compression. Placing the client in the lateral position can help alleviate potential compression of the umbilical cord and improve fetal oxygenation.
D. Increase the rate of maintenance IV infusion.
Increase the rate of maintenance IV infusion: Increasing the IV infusion rate may not be the most appropriate action for late decelerations. Repositioning the client is the priority in this situation.
Full Explanation
A) Administer oxygen using a nonrebreather mask: While oxygen may be necessary if there are signs of fetal distress, the priority action in this situation is to reposition the client and relieve potential cord compression.
B) Elevate the client's legs: Elevating the client's legs is not the most appropriate action in this situation and may not address the cause of the decelerations.
C) Place the client in the lateral position: This is the correct answer. The described pattern of the fetal heart rate (slowdown after the start of a contraction with the lowest rate occurring after the peak of the contraction) suggests late decelerations, which are often caused by uteroplacental
insufficiency or cord compression. Placing the client in the lateral position can help alleviate potential compression of the umbilical cord and improve fetal oxygenation.
D) Increase the rate of maintenance IV infusion: Increasing the IV infusion rate may not be the most appropriate action for late decelerations. Repositioning the client is the priority in this situation.
A nurse in a clinic is reviewing the medical records of a group of clients who are pregnant.
The nurse should anticipate the provider will order a maternal serum alphafetoprotein (MSAFP) screening for which of the following clients?
A. All of the clients
All of the clients: Maternal serum alphafetoprotein (MSAFP) screening is a routine prenatal test offered to all pregnant women, usually between 15 and 20 weeks of gestation. It is used to screen for certain fetal anomalies, including neural tube defects such as spina bifida and anencephaly. Regardless of a client's medical history or risk factors, the MSAFP screening is typically recommended for all pregnant individuals as part of routine prenatal care.
B. A client who has a history of preterm labor
A client who has a history of preterm labor: Preterm labor history is not a specific indication for MSAFP screening. This test is primarily used to screen for fetal anomalies, not preterm labor risk assessment.
C. A client who has mitral valve prolapse
A client who has mitral valve prolapse: Mitral valve prolapse is also not an indication for MSAFP screening. The test is focused on assessing fetal health and not maternal heart conditions.
D. A client who has been exposed to AIDS
A client who has been exposed to AIDS: MSAFP screening is not related to maternal exposure to AIDS. It is a test focused on assessing the fetus's risk of certain congenital abnormalities.
Full Explanation
A) All of the clients: Maternal serum alphafetoprotein (MSAFP) screening is a routine prenatal test offered to all pregnant women, usually between 15 and 20 weeks of gestation. It is used to screen for certain fetal anomalies, including neural tube defects such as spina bifida and anencephaly. Regardless of a client's medical history or risk factors, the MSAFP screening is typically recommended for all pregnant individuals as part of routine prenatal care.
B) A client who has a history of preterm labor: Preterm labor history is not a specific indication for MSAFP screening. This test is primarily used to screen for fetal anomalies, not preterm labor risk assessment.
C) A client who has mitral valve prolapse: Mitral valve prolapse is also not an indication for MSAFP screening. The test is focused on assessing fetal health and not maternal heart conditions.
D) A client who has been exposed to AIDS: MSAFP screening is not related to maternal exposure to AIDS. It is a test focused on assessing the fetus's risk of certain congenital abnormalities.