A nurse is assessing a client who is at 31 weeks of gestation. Which of the following findings should the nurse identify as an indication of a potential prenatal complication?
Periodic tingling of fingers.
Absence of clonus.
Leg cramps.
Blurred vision.
The Correct Answer is D
Choice A rationale:
Periodic tingling of fingers is a common symptom during pregnancy and is often related to hormonal changes and increased fluid retention. While it can be uncomfortable, it is not necessarily an indication of a potential prenatal complication.
Choice B rationale:
Absence of clonus is not an abnormal finding during pregnancy. Clonus is a series of involuntary muscle contractions and relaxations and is generally not expected during a routine assessment.
Choice C rationale:
Leg cramps are a common complaint during pregnancy and are usually caused by changes in calcium and magnesium levels. While they can be uncomfortable, they are not typically considered an indication of a potential prenatal complication.
Choice D rationale:
Blurred vision can be an indication of preeclampsia, a serious condition that can occur during pregnancy. Preeclampsia is characterized by high blood pressure and damage to organs, often affecting the eyes, kidneys, and liver. It is crucial for the nurse to recognize this symptom and promptly inform the healthcare provider for further evaluation and management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice C rationale:
The nurse should first massage the client's fundus to address the excessive vaginal bleeding. Massaging the fundus helps the uterus contract and prevents further bleeding. Excessive postpartum bleeding may indicate uterine atony, which is a leading cause of postpartum hemorrhage. The nurse should apply gentle pressure to the fundus to promote uterine contractions and reduce bleeding.
Choice A rationale:
Elevating the client's legs to a 30° angle (Trendelenburg position) is not the priority action in this situation. Fundal massage takes precedence because it directly addresses the cause of the excessive bleeding. While Trendelenburg position might be used in some situations to increase blood flow to vital organs, it is not the first-line intervention for postpartum bleeding.
Choice B rationale:
Inserting an indwelling urinary catheter is not the priority action for excessive vaginal bleeding. While monitoring urine output is essential, the immediate concern is controlling the bleeding by massaging the fundus.
Choice D rationale:
Initiating an infusion of oxytocin may be indicated if fundal massage alone is insufficient to control bleeding. However, massaging the fundus should be the first action taken to promote uterine contractions. Oxytocin can be administered afterward, if needed, under the direction of a healthcare provider.
Correct Answer is B
Explanation
Choice A rationale:
Hypertonia (increased muscle tone) is not a manifestation of hypoglycemia in a newborn. Instead, hypotonia (decreased muscle tone) is more characteristic.
Choice B rationale:
This is the correct choice. Jitteriness is a common sign of hypoglycemia in a newborn. It may be accompanied by other symptoms like poor feeding, tremors, and irritability.
Choice C rationale:
Acrocyanosis (bluish discoloration of the hands and feet) is a normal finding in newborns and is not specifically associated with hypoglycemia.
Choice D rationale:
Generalized petechiae (small red or purple spots on the skin caused by bleeding under the skin) are not indicative of hypoglycemia but may be associated with other medical conditions.
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