A client in the third trimester of pregnancy is troubled by frequent nasal stuffiness and occasional nosebleeds. Her chest circumference has increased by 5 cm during the pregnancy, and she uses thoracic breathing. Her diaphragm is elevated and she has an increased costal angle. Which intervention should the nurse implement?
Ask a nurse with more experience to validate the costal angle finding.
Examine the client for signs of tissue anoxia, such as pallor.
Ask the healthcare provider to evaluate the client’s respiratory status.
Record the respiratory finding in the client’s record as normal.
The Correct Answer is D
Choice A rationale
Asking another nurse to validate the costal angle finding is unnecessary, as the increased costal angle is a common physiological change during pregnancy due to the expanding uterus.
Choice B rationale
Examining for tissue anoxia, such as pallor, is not relevant in this scenario, as the nasal stuffiness and nosebleeds are likely due to increased blood volume and hormonal changes in pregnancy.
Choice C rationale
Requesting the healthcare provider to evaluate the client's respiratory status is unwarranted, as the described symptoms are typical physiological adaptations during pregnancy and not indicative of respiratory pathology.
Choice D rationale
Documenting the respiratory finding as normal is appropriate, as the increased chest circumference, thoracic breathing, elevated diaphragm, and increased costal angle are expected physiological changes during pregnancy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["36"]
Explanation
Step 1 is: Convert 10 units to milliunits: 10 units × 1,000 milliunits/unit = 10,000 milliunits.
Step 2 is: Calculate the infusion rate: (6 milliunits/min ÷ 10,000 milliunits) × 1,000 mL = 0.6 mL/min.
Step 3 is: Convert the infusion rate to mL/hour: 0.6 mL/min × 60 min/hour = 36 mL/hour. Final calculated answer: 36 mL/hour.
Correct Answer is C
Explanation
Choice A rationale
Glucose water may be soothing due to the sweet taste, but it does not address the immediate need to protect the circumcision site from infection and aid in healing.
Choice B rationale
Liquid acetaminophen provides pain relief, but it does not address the immediate need to protect the circumcision site. Pain management alone is not sufficient for postoperative care.
Choice C rationale
Applying petrolatum gauze dressings on the site prevents the wound from sticking to the diaper, reduces irritation, and protects against infection, promoting healing. This is a priority intervention post-circumcision.
Choice D rationale
While keeping the infant warm is important for comfort and stability, it does not directly address the need to care for the circumcision site to prevent complications and promote healing.
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