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Question

Difficulty: MediumAnte/Intra/Postpartum and Newborn Care

A nurse in the obstetrical triage unit has just received a shift report and must prioritize the initial assessments of four pregnant clients. Based on the provided information, which of the following clients should the nurse assess first?

  1. A client at 34 weeks of gestation who presents with severe, continuous abdominal pain and a rigid, board-like abdomen.Answer
  2. B
    A client at 36 weeks of gestation who reports a sudden gush of clear vaginal fluid 4 hours ago and confirms normal fetal movement.
  3. C
    A client at 12 weeks of gestation who reports persistent nausea and inability to tolerate oral liquids for the past 24 hours.
  4. D
    A client at 28 weeks of gestation who reports bilateral ankle edema that worsens by the end of the day.

Answer

The client at 34 weeks of gestation with severe, continuous abdominal pain and a rigid, board-like abdomen must be assessed first.
The correct answer describes a client exhibiting cardinal signs of abruptio placentae (premature separation of the placenta). A rigid, board-like abdomen and severe, continuous pain are highly indicative of concealed hemorrhage. This is a medical emergency that can rapidly lead to maternal hypovolemic shock, disseminated intravascular coagulation (DIC), and fetal death, making this client the absolute highest priority for assessment and intervention.

Step-by-Step Solution

1
Analyze each client's clinical presentation to identify potential complications.
Identified conditions: abruptio placentae (severe pain, rigid abdomen), premature rupture of membranes (clear fluid), hyperemesis gravidarum (persistent vomiting), and physiological edema.
Understanding the underlying pathology for each symptom is necessary to determine acuity.
2
Apply the principles of triage and the ABCs (Airway, Breathing, Circulation) to prioritize the clients.
The client with a rigid, board-like abdomen is experiencing internal bleeding (Circulation compromise), which is a critical, life-threatening emergency.
Conditions threatening the ABCs or indicating active hemorrhage always take highest priority over localized, chronic, or physiological issues.

Key Concept

Prioritization in Obstetric Emergencies (Abruptio Placentae)
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Topics

Ante/Intra/Postpartum and Newborn Care

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