A nurse is assessing a client who is at 24 weeks of gestation during a routine prenatal exam. Which of the following findings should the nurse report to the provider?
Bleeding gums
Fundal height of 26 cm
Periorbital edema
White vaginal discharge
The Correct Answer is C
A. Bleeding gums: Mild bleeding gums can occur during pregnancy due to increased vascularity and hormonal changes. While uncomfortable, this finding is generally not urgent and can be managed with routine oral care.
B. Fundal height of 26 cm: A fundal height slightly above the gestational age (24 weeks vs. 26 cm) may be within normal variation, especially if the client has a larger fetus or multiple gestations. It should be monitored but is not immediately concerning.
C. Periorbital edema: Swelling around the eyes can be an early sign of preeclampsia, a potentially serious pregnancy complication. This finding should be reported promptly to the provider for further assessment and management.
D. White vaginal discharge: Mild, white, and non-odorous discharge (leukorrhea) is common during pregnancy due to hormonal changes. It is typically considered normal unless accompanied by odor, itching, or irritation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Increased creatinine: Chronic kidney disease reduces the kidneys’ ability to filter waste products effectively, causing creatinine to accumulate in the blood. Elevated creatinine is a key indicator of declining renal function and is expected in this condition.
B. Increased calcium: Clients with chronic kidney disease often have decreased calcium levels due to impaired vitamin D activation and phosphate retention. Increased calcium would be unusual unless the client is receiving supplementation.
C. Increased bicarbonate: Metabolic acidosis is common in chronic kidney disease because the kidneys cannot adequately excrete hydrogen ions or reabsorb bicarbonate. This typically results in decreased, not increased, bicarbonate levels in the blood.
D. Increased hemoglobin: Anemia frequently occurs in chronic kidney disease due to reduced erythropoietin production by the kidneys. This leads to lower hemoglobin levels, so an increase would not be expected unless treated with erythropoiesis-stimulating agents.
Correct Answer is C
Explanation
Rationale:
A. Pull the pinna of the infant's ear forward before inserting the probe: For infants, the pinna should be pulled down and back, not forward, to align the ear canal properly for accurate tympanic temperature measurement.
B. Insert the probe 3.8 cm (1.5 in) into the infant's rectum: Rectal insertion for infants should be limited to 2.5 cm (1 in) or less to avoid rectal perforation and injury. Inserting 3.8 cm is unsafe.
C. Place the tip of the thermometer under the center of the infant's axilla: Axillary temperature measurement is safe and commonly used in infants. Placing the tip in the center of the axilla and holding the arm snugly ensures accurate contact and reading.
D. Insert the oral thermometer in front of the infant's tongue: Infants cannot reliably hold a thermometer under their tongue, making oral measurement inaccurate and unsafe due to risk of swallowing or injury.
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