A nurse is caring for a client who is at 22 weeks of gestation and reports concern about the blotchy hyperpigmentation on her forehead. Which of the following actions should the nurse take?
Tell the client to follow up with a dermatologist
Explain to the client this is an expected occurrence.
instruct the client to increase her intake of vitamin D
Inform the client she might have an allergy to her skin care products
The Correct Answer is B
The correct answer is B. Explain to the client this is an expected occurrence.
A. Tell the client to follow up with a dermatologist: While it's always good to encourage clients to seek professional advice if they have concerns, in the context of melasma during pregnancy, it is generally a normal physiological change. A dermatologist may not be needed specifically for this condition unless there are other unusual symptoms.
B. Explain to the client this is an expected occurrence: This is the correct action. It's important for the nurse to reassure the client that blotchy hyperpigmentation on the forehead is a common and expected change during pregnancy. Providing education and support can help alleviate the client's concerns.
C. Instruct the client to increase her intake of vitamin D: Blotchy hyperpigmentation is not typically addressed by increasing vitamin D intake. While adequate nutrition is important during pregnancy, this specific concern is related more to hormonal changes than nutritional deficiencies.
D. Inform the client she might have an allergy to her skin care products: Melasma is primarily related to hormonal changes in pregnancy rather than an allergic reaction to skin care products. While assessing for allergies is essential in certain situations, it may not be the primary concern in this case.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is C.
A. Acrocyanosis of the extremities: Acrocyanosis, or blueness of the extremities, is a common finding in newborns and is usually considered normal. It often resolves on its own and doesn't typically require intervention.
B. Murmur at the left sternal border: It's not uncommon for newborns to have innocent murmurs, and many resolve on their own as the infant grows. A murmur at the left sternal border alone may not necessarily indicate a problem, but it should be assessed by a healthcare provider.
C. Substernal chest retractions while sleeping: Chest retractions can be a sign of respiratory distress, and intervention is needed to assess and address the cause. Substernal retractions suggest increased work of breathing and may indicate a respiratory issue that requires attention.
D. Positive Babinski reflex: The Babinski reflex is a normal neurological response in infants. It involves the toes fanning out when the sole of the foot is stroked. A positive Babinski reflex is expected in a 12-hour-old newborn and does not require intervention.
Correct Answer is ["{"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}"]
Explanation
A. Apply oxygen at 10 L/min via venturi mask:
Anticipated: Applying oxygen is an appropriate action, especially during labor, to ensure adequate oxygenation for both the mother and the fetus.
B. Increase the oxytocin infusion to 13 mu/min:
Anticipated: Adjusting the oxytocin infusion rate may be considered based on the progress of labor and the response to the current infusion rate. This action is anticipated but should be done cautiously and in accordance with established protocols.
C. Initiate a bolus of primary IV fluids:
Anticipated: Initiating a bolus of primary IV fluids is appropriate, especially if there are signs of dehydration or if additional hydration is needed during labor.
D. Perform a sterile vaginal examination (SVE):
Anticipated: Performing a sterile vaginal examination is appropriate to assess cervical dilation, effacement, and station. This information helps in monitoring the progress of labor and making decisions about interventions.
E. Place the client in a side-lying position:
Anticipated: Placing the client in a side-lying position is an appropriate action. This position can enhance fetal oxygenation and blood flow, especially if there are concerns about fetal well-being.
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