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 B
Explanation
Rationale:
A. "I will hang a pastel-colored mobile 24 inches above my baby's crib.": Newborns can only see objects clearly 8–12 inches away and are more attracted to bold patterns and contrasting colors. A mobile 24 inches away would be too far for visual stimulation.
B. "I will place a ticking clock nearby to soothe my baby throughout the day.": Rhythmic sounds, such as a ticking clock, can mimic the intrauterine environment and help calm newborns. This is an appropriate soothing technique for a 1-week-old.
C. "I will avoid picking up my baby too often to keep from spoiling him.": Holding and responding promptly to a newborn’s needs promotes bonding, emotional security, and healthy development. At this age, infants cannot be spoiled.
D. "I can use a firm pillow to prop up the bottle when feeding my baby.": Propping bottles increases the risk of choking, aspiration, and otitis media. Infants should always be held during feedings for safety and bonding.
Correct Answer is C
Explanation
A. Documenting communication with a provider in the progress notes of the client's medical record: Proper documentation of provider communication is standard nursing practice and does not constitute malpractice. It helps ensure continuity of care and legal protection.
B. Placing a yellow bracelet on a client who is at risk for falls: Implementing fall precautions, such as using a yellow wristband, is an appropriate safety measure and standard of care, not malpractice.
C. Administering potassium via IV bolus: Administering potassium as a rapid IV push is extremely dangerous and can cause cardiac arrest. This action violates the standard of care and constitutes malpractice due to potential harm to the client.
D. Leaving a nasogastric tube clamped after administering oral medication: A nasogastric (NG) tube is often clamped for a short period after administering medication to allow the medication to be absorbed. The nurse's action would only be considered negligent if they left the tube clamped for a prolonged period.
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