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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Related Questions
Correct Answer is B
Explanation
Choice A reason: Massaging a DVT risks dislodging the clot, causing embolism. In postpartum with anticoagulants, this is contraindicated to prevent lethal complications.
Choice B reason: Bed rest minimizes clot movement in DVT, aiding anticoagulation postpartum. It reduces embolism risk, a critical safety measure in this scenario.
Choice C reason: Ice may reduce swelling, but it’s not standard for DVT with anticoagulants. Elevation and rest are prioritized over cold therapy here.
Choice D reason: Aspirin isn’t used with anticoagulants like heparin; it increases bleeding risk. Postpartum DVT needs specific pain management, not this drug.
Correct Answer is C
Explanation
Choice A reason: Droplet precautions need a mask, not always gown and gloves, unless contact is likely. Scientifically, this overstates requirements, as droplet spread (e.g., flu) prioritizes respiratory protection, indicating partial misunderstanding of PPE specifics.
Choice B reason: Bleach at 1:20 is too dilute; 1:10 is standard for blood spills. Scientifically, this weakens disinfection, as higher chlorine concentration kills pathogens like hepatitis, showing incorrect grasp of spill management protocols.
Choice C reason: Biohazard disposal for soiled dressings prevents pathogen spread, aligning with infection control. Scientifically, this ensures safe waste handling, as dressings may harbor bacteria or viruses, reflecting accurate understanding of standard precautions.
Choice D reason: Alcohol doesn’t kill C. difficile spores; soap and water are required. Scientifically, this misapplies hand hygiene, as spore-forming bacteria resist alcohol, indicating a key error in infection control knowledge for this pathogen.
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