Question

A nurse at a provider's office is caring for a client who is 28 years of age.

Complete the following sentence by using the list of options.

History and Physical
Day 1 at 1000:
Gravida 3, Para 2, Abortion 1
Asthma (managed with levalbuterol inhaler as needed)
Pelvic inflammatory disease (PID)
Spontaneous vaginal delivery X 2 (hypertension with first pregnancy at 20 years of age)
Voluntary termination of pregnancy (3rd pregnancy)

Nurses' Notes
Day 1 at 1000:
Client presents to the office with concerns of late menses, abdominal pain, and scant dark red vaginal spotting. Client reports menstrual period is usually regular and is 2 weeks late. Last menstrual period: 2/20/XX. Client reports occasional dull abdominal pain and rates it as 2 on a 0 to 10 pain scale. Client is alert and oriented, appears anxious. Speech clear. Skin warm and dry to touch. Heart rate regular at 90/min. Respirations even and non-labored. Lungs slight inspiratory wheezes. Bowel sounds hyperactive in all four quadrants. Abdomen tender to touch right lower quadrant. Perineal pad with scant amount of dark red vaginal spotting.

Vital Signs
Day 1 at 1000:
Temperature 37.2° C (98.9° F), Heart rate 90/min, Respirations 16/min, Blood pressure 120/74 mm Hg, Oxygen saturation 97% room air
Day 1 at 1030:
Temperature 37.2° C (98.9° F), Heart rate 104/min, Respirations 18/min, Blood pressure 116/70 mm Hg, Oxygen saturation 97% room air

Diagnostic Results
Day 1 at 1015:
Urine human chorionic gonadotropin (HCG) positive (negative)
Day 1 at 1030:
Blood human chorionic gonadotropin (hCG) 50 IU/L (less than 5 IU/L)
Quantitative beta human chorionic gonadotropin (β-hCG) 20,000 IU/L (negative)
Progesterone 4 ng/dL (1st trimester 725 to 4400 ng/dL)
Hgb 11 g/dL (12 to 16 g/dL)
Hct 35% (37 to 47%)
Platelets 152,000/mm3 (150,000 to 300,000/mm3)


The nurse should first address the client's
A. Lung sounds
B. Heart rate
C. Bowel sounds

Followed by the client's
A. Vaginal spotting
B. Hemoglobin level
C. Anxiety

Answer 1

The nurse should first address the client's lung sounds due to inspiratory wheezes, indicating a possible asthma exacerbation. Next, the nurse should assess the client's vaginal spotting, considering the positive pregnancy tests and previous PID, which indicates potential pregnancy complications. Lastly, the client's anxiety should be addressed once immediate physiological concerns are managed.

Step-by-step explanation:

The nurse caring for a 28 years of age client should prioritize the assessment and management of clinical findings in a systematic way. The nurse should first address the slight inspiratory wheezes heard in the client's lungs, as this could indicate an acute asthma exacerbation, especially given her history of asthma, which could quickly escalate and become life-threatening. The nurse should also note the increased heart rate from 90/min to 104/min over 30 minutes, which could be a stress response or related to potential early pregnancy changes. However, the urgency to address asthma symptoms generally takes precedent over an elevated heart rate in the absence of other immediate life-threatening signs.

Following the assessment and initial intervention for the client's lung sounds, the nurse should address the vaginal spotting. Given the positive hCG tests and the previous history of PID, this could represent a pregnancy with potential complications such as an ectopic pregnancy or a threatened miscarriage. The client's anxiety is also an important aspect to consider in providing holistic care, but the physiological assessments should take primary focus initially due to potential immediate risks to the client's health.