A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider?
Swelling of the face
Varicose veins in the calves
Nonpitting 1+ ankle edema
Hyperpigmentation of the cheeks
The Correct Answer is A
The correct answer is A.
A. Swelling of the face: Facial swelling, especially sudden or severe swelling, could be a sign of preeclampsia, a serious pregnancy complication characterized by high blood pressure and organ dysfunction. Any new or significant facial swelling should be promptly reported to the healthcare provider for evaluation.
B. Varicose veins in the calves: Varicose veins are a common occurrence during pregnancy due to increased pressure on the veins. While they can cause discomfort, they are generally not considered a significant concern unless there are signs of complications, such as inflammation or blood clots.
C. Nonpitting 1+ ankle edema: Mild ankle edema is relatively common during pregnancy and may not be concerning unless it becomes severe, sudden, or is associated with other symptoms. Nonpitting edema is generally less concerning than pitting edema but should still be monitored.
D. Hyperpigmentation of the cheeks: Hyperpigmentation, often referred to as the "mask of pregnancy" or melasma, is a common and benign condition during pregnancy. While it may be bothersome to some individuals, it is not typically a concern that requires immediate reporting to the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Drinking the glucose solution 2 hours prior to the test is not standard for a 1-hour GTT. Instead, the glucose solution is usually consumed within a short timeframe, such as 5 minutes, and the blood is drawn 1 hour afterward.
Choice B Reason:
Limiting carbohydrate intake for 3 days prior to the test is not a requirement for a 1-hour GTT. However, it may be advised for a longer fasting period or a different type of glucose tolerance test.
Choice C Reason:
C. “A blood glucose of 130 to 140 is considered a positive screening result.”
In the 1-hour glucose tolerance test during pregnancy, a blood glucose level of135 mg/dL or higheris considered a positive screening result. If this threshold is met, further testing (such as the 3-hour glucose tolerance test) is recommended to confirm or rule out gestational diabetes.
.
Choice D Reason:
Fasting for 12 hours prior to the test is inappropriate. For a 1-hour GTT, the client is not typically required to fast.
Correct Answer is ["{"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}"]
Explanation
A. Apply oxygen at 10 L/min via venturi mask:
Anticipated: Applying oxygen is an appropriate action, especially during labor, to ensure adequate oxygenation for both the mother and the fetus.
B. Increase the oxytocin infusion to 13 mu/min:
Anticipated: Adjusting the oxytocin infusion rate may be considered based on the progress of labor and the response to the current infusion rate. This action is anticipated but should be done cautiously and in accordance with established protocols.
C. Initiate a bolus of primary IV fluids:
Anticipated: Initiating a bolus of primary IV fluids is appropriate, especially if there are signs of dehydration or if additional hydration is needed during labor.
D. Perform a sterile vaginal examination (SVE):
Anticipated: Performing a sterile vaginal examination is appropriate to assess cervical dilation, effacement, and station. This information helps in monitoring the progress of labor and making decisions about interventions.
E. Place the client in a side-lying position:
Anticipated: Placing the client in a side-lying position is an appropriate action. This position can enhance fetal oxygenation and blood flow, especially if there are concerns about fetal well-being.
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