A nurse is caring for a 26-year-old female client who is at 14 weeks of gestation in the antepartum clinic.
Select the 3 findings that are unexpected.
Weight loss
Breast tenderness
Heart rate
Vomiting
Nasal congestion
Respiratory rate
Correct Answer : A,C,D
Choice A rationale: Weight loss
Weight loss during pregnancy, especially in the second trimester, is unexpected unless there is a medical condition such as hyperemesis gravidarum or other nutritional deficiencies. While mild weight fluctuations can occur, a consistent loss of weight rather than gradual gain suggests inadequate caloric intake due to persistent vomiting and dehydration.
Choice B rationale: Breast tenderness
Breast tenderness is a common and expected physiological change during pregnancy due to hormonal fluctuations, particularly increased estrogen and progesterone levels. It is not considered abnormal or unexpected at this stage of pregnancy.
Choice C rationale: Heart rate
A heart rate of 116/min is unexpected, as it is above the normal range for adults (typically 60–100/min). Pregnancy can cause a mild increase in heart rate, but tachycardia above 110/min may indicate dehydration, anemia, or electrolyte imbalance, all of which can stem from excessive vomiting and fluid loss.
Choice D rationale: Vomiting
While occasional nausea and vomiting (morning sickness) can be expected in early pregnancy, persistent vomiting up to eight times daily and symptoms of dehydration (dry mucosa, poor skin turgor, positive ketones in urine) raise concern for hyperemesis gravidarum, a more severe form of pregnancy-related nausea and vomiting.
Choice E rationale: Nasal congestion
Nasal congestion is common during pregnancy due to increased blood volume and vascular changes affecting the nasal mucosa. It is not unexpected and does not indicate a complication.
Choice F rationale: Respiratory rate
A respiratory rate of 20/min falls within the normal range for adults (typically 12–20/min), making it an expected finding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Unconjugation of bilirubin is the process where bilirubin, initially produced in a water-insoluble form (unconjugated or indirect bilirubin), is not yet processed by the liver. This form cannot be easily excreted by the body.
Choice B rationale
Albumin binding refers to the transport of unconjugated bilirubin in the bloodstream. Because unconjugated bilirubin is fat-soluble and not easily dissolved in water, it binds to albumin, a protein in the blood, which allows it to be transported to the liver.
Choice C rationale
The enterohepatic circuit describes the circulation of bile acids from the liver to the small intestine, where they aid in fat digestion and absorption, and then back to the liver. Bilirubin is a byproduct of heme breakdown and is processed separately in the liver before excretion in bile.
Choice D rationale
Conjugation of bilirubin is the process that occurs in the liver where the enzyme uridine diphosphoglucuronate glucuronosyltransferase (UGT) attaches glucuronic acid molecules to unconjugated bilirubin. This process transforms the fat-soluble unconjugated bilirubin into a water-soluble form called conjugated (or direct) bilirubin, which can then be excreted in bile into the intestines.
Correct Answer is D
Explanation
Choice A rationale
Applying heat to the breasts in mastitis can increase blood flow and potentially worsen inflammation. While heat can be comforting for engorgement, in mastitis, it may exacerbate the inflammatory response and should be used cautiously or avoided in the acute phase. The primary goal is to remove milk and reduce inflammation.
Choice B rationale
Removing the nursing bra might provide some temporary comfort if the bra is too tight and constricting milk flow. However, it does not address the underlying infection or inflammation of mastitis. Supportive nursing bras are generally recommended to provide support without restricting milk ducts.
Choice C rationale
Given the early indications of mastitis, such as a hard, warm area in the breast, moderate lochia rubra (which is normal for postpartum day 3), and a fundus appropriately descended, additional interventions are indeed indicated to prevent the progression of the infection and promote healing. Ignoring these signs could lead to a more severe infection.
Choice D rationale
Continued breastfeeding is crucial for managing mastitis. Frequent emptying of the breasts helps to remove the stagnant milk, which can contribute to the infection. Breast milk has antimicrobial properties that can aid in resolving the infection. Encouraging the client to breastfeed frequently on the affected side, starting with that side, promotes drainage and healing.
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