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 D
Explanation
Choice A reason: Difficulty swallowing isn’t a typical pain sign from epidural failure; it suggests throat or nerve issues unrelated to disc pain. Scientifically, this lacks connection to spinal analgesia efficacy, as herniated disc pain manifests elsewhere, not in pharyngeal function.
Choice B reason: Constipation may result from opioids in epidurals, not unrelieved pain. It’s a side effect, not a pain indicator. Scientifically, bowel changes reflect medication impact, not disc pain intensity, making this an unreliable marker for epidural effectiveness.
Choice C reason: Urinary retention is an epidural side effect from nerve blockade, not a direct pain signal. Scientifically, it indicates spinal anesthesia depth, not failure to relieve herniated disc pain, distinguishing it from pain-specific behavioral cues.
Choice D reason: Clenched teeth reflect facial tension, a common involuntary response to unrelieved spinal pain. Scientifically, this aligns with pain behavior studies, as muscle guarding and grimacing indicate persistent disc-related discomfort, signaling epidural inadequacy effectively.
Correct Answer is B
Explanation
Choice A reason: A 90-degree angle is too upright; newborns need a 30-45-degree recline to protect airways. This shows misunderstanding of safe positioning.
Choice B reason: Rear-facing until age 2 supports neck and spine safety, per guidelines. This reflects correct understanding of car seat standards for newborns.
Choice C reason: Retainer clips belong at chest level, not belly, for harness safety. This indicates incorrect knowledge of car seat strap placement.
Choice D reason: Airbags endanger front-seat infants; rear seating is mandatory. Enabling them shows a dangerous misunderstanding of car seat safety protocols.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.