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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

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

Choice D rationale

A. Administer a PRN dose of acetaminophen. B. Assess perineum for excessive lochia. C. Document the vital signs in the record. D. Report heart rate to healthcare provider.

Correct Answer is C

Explanation

Choice A rationale

Administering acetaminophen is not indicated as the temperature of 100.4° F (38° C) is within the normal postpartum range, often due to dehydration or breast engorgement. Acetaminophen should be used cautiously and only if necessary.

Choice B rationale

Assessing perineum for excessive lochia is unnecessary here, as the current vital signs do not indicate hemorrhage. Normal postpartum bleeding gradually decreases in amount and should be monitored accordingly but not prompted by these vitals.

Choice C rationale

Documentation of vital signs is essential to maintain accurate medical records and track any changes in the patient's condition. Accurate records help in identifying trends and making informed decisions about patient care.

Choice D rationale

Reporting a heart rate of 58 beats/minute is unnecessary because bradycardia can be normal in postpartum women, especially if they have good cardiovascular fitness. It is important to monitor for other symptoms before taking further action.

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4° F (38° C), heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 130/74 mm Hg. Which action should the nurse implement?

Correct Answer is C

Explanation

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