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. Contractions lasting longer than 90 seconds.

A. Contractions lasting longer than 90 seconds can be indicative of a prolonged contraction, which may affect uteroplacental perfusion and fetal oxygenation. This is a concern and should be reported to the provider.

B. Contractions occurring every 3 to 5 minutes are within the normal frequency range during the active phase of the first stage of labor.

C. The client reporting feeling contractions in the lower back is a common description of back labor, which may occur due to the position of the baby. It is not necessarily a cause for immediate concern unless it is associated with other issues.

D. Contractions being strong in intensity is expected during the active phase of labor. Strong contractions are necessary for cervical dilation and the progression of labor.

A. Administer oxygen to the client B. Turn the client onto her side C. Increase the client's IV fluid infusion rate D. Palpate the client's uterus

Correct Answer is B

Explanation

The correct answer is B. Turn the client onto her side.

A. Administering oxygen to the client is a reasonable intervention in the presence of late decelerations, but turning the client onto her side is the priority action to relieve potential compression of the vena cava and improve fetal oxygenation.

B. Turning the client onto her side is the correct first action.

Late decelerations are often associated with uteroplacental insufficiency. Changing the client's position, especially to the left lateral position, can help alleviate pressure on the vena cava, improving blood flow to the uterus and fetal oxygenation.

C. Increasing the client's IV fluid infusion rate may be considered, but it is not the first action to address late decelerations. Positioning changes should be initiated promptly.

D. Palpating the client's uterus is an assessment that may be done, but it is not the first action when late decelerations are observed. Positioning changes take precedence.

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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 the active phase of the first stage of labor. When monitoring the uterine contractions, which of the following findings should the nurse report to the provider?

Correct Answer is A

Explanation

A nurse is caring for a client who is in active labor when the client's membranes rupture. The fetal monitor tracing shows late decelerations Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

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