A nurse is caring for a client who is at 34 weeks of gestation. Which of the following statements by the client is the nurse’s priority to report to the provider?
"My heart feels like it skips a beat."
"I have nosebleeds once per week."
"The palms of my hands are red and blotchy."
"I’m experiencing persistent headaches."
The Correct Answer is A
Choice A reason: Palpitations at 34 weeks may signal arrhythmia or preeclampsia-related cardiac strain. This urgent symptom in pregnancy requires immediate provider evaluation.
Choice B reason: Weekly nosebleeds are common in pregnancy from vascular changes, less critical. Without severity, they’re not the priority over cardiac concerns.
Choice C reason: Red, blotchy palms (palmar erythema) are normal in pregnancy from estrogen. It’s benign, not urgent compared to potential heart issues.
Choice D reason: Persistent headaches suggest preeclampsia, but palpitations pose a more immediate cardiac risk. At 34 weeks, this takes reporting precedence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Puffed rice cereal lacks significant fiber, offering minimal bulk to stimulate peristalsis. It’s a poor choice for constipation relief, as it doesn’t soften stool or aid movement.
Choice B reason: Tomato juice provides hydration and some nutrients, but its low fiber content doesn’t effectively combat constipation. High-fiber foods are needed to increase stool bulk instead.
Choice C reason: Bran muffins are high in insoluble fiber, adding bulk and water to stool, promoting bowel movements. This choice reflects understanding of constipation management through diet.
Choice D reason: Cottage cheese is low in fiber, offering protein but no relief for constipation. It doesn’t enhance intestinal motility or stool consistency, making it an ineffective option.
Correct Answer is C
Explanation
Choice A reason: Facial erythema is not a hallmark of pertussis, caused by Bordetella pertussis. It may occur in scarlet fever from Streptococcus, but pertussis features paroxysmal coughing and whooping, not facial redness, making this uncharacteristic of the respiratory infection’s typical presentation.
Choice B reason: Peeling of hands and feet is typical of Kawasaki disease or scarlet fever post-streptococcal infection, not pertussis. Pertussis affects the respiratory tract, causing mucus buildup and coughing, not dermatologic desquamation, which is unrelated to its bacterial pathogenesis.
Choice C reason: Fever is expected in pertussis as the body mounts an immune response to Bordetella pertussis, elevating temperature to fight infection. Though not always high, it accompanies the catarrhal phase, reflecting systemic inflammation, a common sign in respiratory bacterial infections.
Choice D reason: Beefy, red tongue is a feature of scarlet fever or vitamin deficiencies, not pertussis. Pertussis targets the respiratory system, causing coughing and whooping, not oral mucosal changes, making this unrelated to its pathophysiology, focusing on airway irritation.
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