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."

Answer and Explanation

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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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.

A. Diminished pulses on the affected extremity B. Ecchymosis on the inner left thigh C. Client report of muscle spasms of the left leg D. One fingerbreadth of space between the cast and the skin

Correct Answer is A

Explanation

Choice A reason: Diminished pulses signal compromised circulation, a critical cast complication like compartment syndrome. This risks tissue necrosis or amputation if untreated, prioritizing it scientifically, as arterial flow disruption demands immediate intervention to preserve limb viability per vascular assessment standards.

Choice B reason: Ecchymosis suggests bruising, possibly from cast pressure, but isn’t immediately life-threatening like poor circulation. It’s a secondary concern, manageable later. Scientifically, it indicates trauma, not acute vascular emergency, ranking lower in urgency per cast complication protocols.

Choice C reason: Muscle spasms may indicate irritation or pressure, but they’re less urgent than absent pulses. Pain is common in casts, not always critical. Scientifically, this suggests nerve or muscle stress, not imminent tissue loss, making it a lower priority for immediate action.

Choice D reason: One fingerbreadth space is normal, preventing tightness, not a concern. It’s ideal fit, not a problem. Scientifically, this aligns with safe cast application, lacking urgency compared to circulatory threats, as it supports, rather than jeopardizes, limb health.

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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?

Nursing Test Bank

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