A nurse is caring for a client who is at 32 weeks gestation and has a history of hypertension. Which of the following statements by the client should the nurse report to the provider?
"My ankles get swollen after standing at work."
"My gums bleed when I brush my teeth."
"I have constant pain in the middle of my upper abdomen."
"I feel dizzy when I lay flat on my back.
The Correct Answer is C
Choice A rationale:
Ankle swelling can be a common symptom of pregnancy and is not necessarily indicative of a complication.
Choice B rationale:
Gums can become more sensitive during pregnancy, leading to bleeding while brushing teeth. This finding is common and not necessarily indicative of a complication.
Choice C rationale:
Constant pain in the middle of the upper abdomen can be a sign of preeclampsia, a serious pregnancy complication that requires prompt medical attention.
Choice D rationale:
Feeling dizzy when lying flat on the back (supine hypotension) can be a common discomfort during pregnancy due to pressure on the vena cava. However, it does not necessarily indicate a complication in this context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Padded wrist restraints are not appropriate unless there's a clear clinical indication to prevent self-harm or injury.
Choice B rationale:
After a seizure, it's important to establish IV access for the client to administer medications, fluids, or other interventions if needed. Monitoring for possible postictal state, airway patency, and vital signs are also important components of care.
Choice C rationale:
Administering lorazepam every 4 hours is not a standard protocol for post-seizure management and could lead to excessive sedation.
Choice D rationale:
Placing an incontinence brief is not necessary unless there's a specific indication, and it doesn't directly relate to post-seizure care.
Correct Answer is B
Explanation
Choice A rationale:
Abdominal cramps are not typically associated with opioid intoxication. Choice B rationale:
Opioid intoxication can cause symptoms such as slowed or slurred speech, drowsiness, and altered mental status.
Choice C rationale:
Opioid intoxication often leads to bradycardia (slower heart rate), not tachycardia (faster heart rate).
Choice D rationale:
Diaphoresis (excessive sweating) is a symptom of opioid withdrawal, not intoxication.
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