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

Answer and Explanation

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.

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Correct Answer is A

Explanation

The correct answer is A. Slow-paced breathing

A. Slow-paced breathing is a nonpharmacological comfort measure that involves taking slow, deep breaths to promote relaxation and reduce anxiety. It can be an effective technique for managing pain during contractions.

B. Biofeedback involves the use of electronic monitoring to provide feedback about physiological processes, and it is not typically used as a primary nonpharmacological comfort measure for labor pain.

C. Self-hypnosis is a relaxation technique that involves guided imagery and focused concentration to promote relaxation and reduce pain. However, it may require some previous knowledge or practice, and in the context of this scenario, slow-paced breathing may be a more immediate and accessible option.

D. Acupuncture involves the insertion of needles into specific points on the body to stimulate energy flow. While acupuncture can be effective for pain management, it may not be readily available in all labor settings, and slow-paced breathing is a more universally applicable option.

A. Administer oxygen at 10 L/min via a nonrebreather mask. B. Change the client's position. C. Apply a fetal scalp electrode D. Increase the rate of the TV infusion

Correct Answer is B

Explanation

A. Administering oxygen at 10 L/min via a nonrebreather mask is an important intervention, but changing the client's position is the priority action when late decelerations are observed. Oxygen administration can follow, but optimizing uteroplacental perfusion through changing position is crucial.

B. Changing the client's position is the correct first action.

Repositioning the client, particularly from a supine to a side-lying position, can help alleviate compression on the vena cava and improve blood flow to the uterus, reducing the likelihood of late decelerations.

C. Applying a fetal scalp electrode is not the initial action when late decelerations are noted. Repositioning the client should be attempted first to address potential issues related to uteroplacental perfusion.

D. Increasing the rate of the intravenous (IV) infusion might not directly address the issue of late decelerations. It's important to focus on maternal positioning first to improve blood flow to the uterus.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in labor and is reporting intense pain during contractions. The client has no previous knowledge of nonpharmacological comfort measures. Which of the following nursing interventions should the nurse implement?

Correct Answer is A

Explanation

A nurse is caring for a client who is in active labor and notes late decelerations in the FHR. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

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