A nurse in an antepartum unit is triaging clients. Which of the following clients should the nurse see first?

Correct Answer: D

Rationale: In this scenario, the nurse should prioritize seeing the client who is at 28 weeks of gestation and reports painless vaginal bleeding (Option D) first. This is because painless vaginal bleeding in the third trimester can be indicative of placenta previa or abruptio placentae, both of which are serious obstetric emergencies requiring immediate evaluation and intervention to prevent maternal and fetal complications. Option A is incorrect because while cough and fever in a late-term pregnancy should be assessed promptly, they do not pose an immediate threat to the client or the fetus as compared to painless vaginal bleeding in the third trimester. Option B is incorrect as vaginal spotting in early pregnancy could be indicative of a threatened miscarriage, but it is not as urgent as painless vaginal bleeding in the third trimester. Option C is incorrect as nausea and vomiting in the first trimester are common symptoms of early pregnancy and do not require immediate attention unless they are severe and causing dehydration or other complications. Educationally, this question highlights the importance of prioritizing care based on the acuity of the situation in maternal-newborn nursing. It underscores the significance of recognizing obstetric emergencies and the need for swift action to ensure the safety and well-being of both the mother and the baby.

Correct Answer: B

Rationale: Choice B, 'I will reduce my exercise schedule to 3 days a week,' indicates a need for further teaching. Regular exercise is beneficial in managing gestational diabetes and should not be reduced without proper guidance. Choices A, C, and D demonstrate understanding and appropriate actions in managing gestational diabetes.

Correct Answer: A

Rationale: The correct response is to acknowledge and validate the client's feelings of disappointment. This empathetic approach demonstrates understanding and support for the client's emotional state, fostering a therapeutic nurse-client relationship. Options B, C, and D do not address the client's emotional needs or provide appropriate support in this situation.

Correct Answer: A

Rationale: The nurse should prioritize seeing the client who experienced a cesarean birth 4 hours ago and reports pain first. Pain assessment and management are crucial post-cesarean birth to ensure the client's comfort and well-being. Immediate attention is needed to address the client's pain and provide appropriate interventions. The other clients may require attention but do not have an immediate postoperative concern like pain following a cesarean birth.

Correct Answer: B

Rationale: A respiratory rate of 16/min within the normal range is an essential parameter to monitor when administering magnesium sulfate, as respiratory depression is a potential adverse effect. Diminished deep-tendon reflexes may indicate magnesium toxicity, warranting immediate intervention. A urine output of 50 mL in 4 hours is below the expected amount, suggesting decreased kidney perfusion, which can be exacerbated by magnesium sulfate. A heart rate of 56/min is bradycardic and may indicate magnesium toxicity, requiring assessment and possible discontinuation of the infusion.