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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Counterpressure helps back labor pain, not cesarean incision pain. It targets muscle tension, not surgical site discomfort, which stems from tissue trauma. For a day-old cesarean, this misaligns with pain source, lacking scientific support for reducing abdominal strain during position changes post-surgery.
Choice B reason: Limiting position changes reduces mobility, risking complications like thrombosis or stiffness post-cesarean. Movement aids recovery, and pain management should facilitate, not hinder, it. This advice contradicts evidence-based practice promoting early ambulation, making it an ineffective and potentially harmful nonpharmacological strategy.
Choice C reason: Splinting the incision with a pillow supports the abdominal wall, reducing strain on sutures during movement. This decreases pain from muscle stretching post-cesarean, aligning with scientific principles of mechanical support, making it an effective, evidence-based nonpharmacological method to manage discomfort safely.
Choice D reason: Patterned breathing aids labor or anxiety, not surgical pain. It distracts from discomfort but does not address physical strain on the cesarean incision during position changes. Lacking direct mechanical relief, it’s less effective scientifically compared to splinting for this specific postoperative pain context.
Correct Answer is A
Explanation
Choice A reason: Sitting positions the belt restraint safely at the waist, minimizing injury risk. It allows breathing and circulation, critical when managing aggression safely.
Choice B reason: Tying to bed rails restricts mobility excessively, risking injury if the bed moves. Proper restraint secures to a fixed frame, not rails.
Choice C reason: Chest placement impairs breathing, a dangerous error in restraint use. Belt restraints belong at the waist to avoid respiratory compromise.
Choice D reason: Under-clothing application risks skin abrasion and monitoring issues. Restraints over clothes ensure visibility and safety, per standard aggression protocols.
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