A nurse is assessing a client who is in the third trimester of pregnancy. The nurse should recognize which of the following findings as an expected physiologic change during pregnancy?
Posterior neck flexion
Increased abdominal muscle tone
Gradual lordosis
Decreased mobility of pelvic joints
The Correct Answer is C
Choice A: Posterior neck flexion is not an expected change during pregnancy.
Choice B: Increased abdominal muscle tone is not an expected change during pregnancy. In fact, the abdominal muscles tend to stretch and may become less toned as the uterus expands.
Choice C: During pregnancy, the woman's center of gravity shifts due to the growing uterus, leading to an increased arch in the lower back known as lordosis. This change helps to maintain balance and reduce the strain on the back. The other options are not expected physiologic changes during pregnancy.
Choice D: Decreased mobility of pelvic joints is not an expected change during pregnancy. Some joint laxity may occur due to hormonal changes, but decreased mobility is not typical.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
The correct answer is B, C, and D.
Choice A: Increase the oxytocin infusion to 13 mu/min
Increasing the oxytocin infusion is not indicated in this scenario. Oxytocin is used to induce or augment labor, but if the fetal heart rate tracing is abnormal (Category 3), increasing oxytocin could exacerbate fetal distress. The priority is to stabilize the fetal condition before considering increasing oxytocin.
Choice B: Initiate a bolus of primary IV fluids
Initiating a bolus of primary IV fluids is appropriate. This action helps improve placental perfusion and maternal hydration, which can be beneficial in response to abnormal fetal heart rate tracings. Adequate hydration can enhance uteroplacental blood flow and improve fetal oxygenation.
Choice C: Place the client in a sidelying position
Placing the client in a sidelying position is recommended. This position can improve uteroplacental perfusion and fetal oxygenation, especially if there are signs of fetal distress. It helps to alleviate pressure on the inferior vena cava, enhancing blood flow to the placenta.
Choice D: Apply oxygen at 10 L/min via a venturi mask
Applying oxygen at 10 L/min via a venturi mask is indicated for improving fetal oxygenation in cases of abnormal fetal heart rate patterns. This intervention can help increase the oxygen available to the fetus, which is crucial in managing fetal distress.
Choice E: Perform a sterile vaginal examination (SVE)
Performing a sterile vaginal examination (SVE) is not indicated based on the provided assessment findings. While SVE is useful for assessing cervical dilation and labor progression, it is not a priority in this situation where the main concern is fetal well-being. Unnecessary SVEs can increase the risk of infection.
Correct Answer is C
Explanation
Choice A: While an upright position is generally beneficial during labor to improve uterine contractions and fetal positioning, it is not the priority in this situation of hypotension.
Choice B: Preparing for a cesarean birth is not indicated solely based on the blood pressure reading. Cesarean birth should be considered based on the overall assessment and clinical condition of the client and baby.
Choice C: The client's blood pressure reading of 82/52 mm Hg indicates hypotension. In this situation, the nurse should assist the client in turning onto her side to relieve pressure on the vena cava and improve blood flow to the placenta and the baby. Lying supine can compress the vena cava, leading to decreased venous return and reduced cardiac output, which may negatively affect fetal oxygenation and maternal wellbeing.
Choice D: Preparing for an immediate vaginal delivery is not the priority at this moment. The nurse should first address the hypotension and improve maternal blood flow before proceeding with delivery.
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