A nurse is caring for a client who is at 36 weeks of gestation.
Which of the following findings should the nurse identify as the priority to assess further?
Increased leukorrhea.
Urinary frequency.
Persistent headache.
Insomnia.
The Correct Answer is C
Choice A rationale
Increased leukorrhea, or vaginal discharge, is a common and normal physiological finding during pregnancy due to increased estrogen levels and blood flow to the vaginal area. This increase in discharge helps prevent ascending infections. Unless accompanied by itching, odor, or color changes, it typically does not indicate a problem.
Choice B rationale
Urinary frequency is a common symptom in late pregnancy, particularly in the third trimester. It results from the enlarging uterus compressing the bladder, reducing its capacity, and increasing renal blood flow and glomerular filtration rate, leading to increased urine production. It is a normal physiological adaptation.
Choice C rationale
A persistent headache in a pregnant client, especially in the third trimester, is a priority to assess further because it can be a sign of preeclampsia, a serious hypertensive disorder of pregnancy. Other symptoms of preeclampsia include visual disturbances, right upper quadrant pain, and proteinuria. Early identification is crucial for intervention.
Choice D rationale
Insomnia is a common complaint during the third trimester of pregnancy. It can be attributed to various factors such as physical discomfort, frequent urination, fetal movements, anxiety, and hormonal changes. While bothersome, it is generally considered a normal, though often challenging, aspect of late pregnancy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Premature newborns have immature respiratory and neurological systems, making them vulnerable to respiratory compromise and apnea in a car seat. A car seat test prior to discharge assesses their ability to maintain adequate oxygenation and heart rate while positioned in the car seat for a prolonged period, ensuring safety.
Choice B rationale
The retainer clip should be positioned at the level of the newborn's armpits, not the abdomen. Proper placement at the armpit level ensures that the harness straps are snug over the shoulders and chest, effectively restraining the infant and preventing ejection in the event of a collision, optimizing crash protection.
Choice C rationale
Newborns, especially premature ones, must always be placed in a rear-facing car seat in the back seat of the vehicle. Rear-facing provides optimal support for the newborn's fragile head, neck, and spine, distributing crash forces over the entire back and significantly reducing the risk of severe injuries in a collision.
Choice D rationale
The recommended angle for a rear-facing car seat is typically between 30 to 45 degrees, depending on the specific car seat model, not 60 degrees. This recline angle is crucial to prevent the newborn's head from falling forward and compromising their airway, which is particularly critical for a premature infant with underdeveloped neck control. .
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B"},"C":{"answers":"A"},"D":{"answers":"A,B"}}
Explanation
Abruptio Placentae: Typically does not cause increased contraction frequency; contractions may be normal or decreased due to uterine irritation or pain.
Uterine Tachysystole: Characterized by more than 5 contractions in 10 minutes averaged over 30 minutes, indicating excessive contraction frequency, which can reduce uteroplacental perfusion.
Uterine Tone
Abruptio Placentae: The uterus often becomes firm, rigid, and tender due to bleeding and inflammation caused by premature placental separation, increasing baseline uterine tone.
Uterine Tachysystole: Uterine tone is elevated because contractions are prolonged and close together, causing the uterus to remain tense with insufficient relaxation.
Pain Report
Abruptio Placentae: Patients usually report sharp, severe abdominal or back pain due to the sudden placental detachment and uterine irritation.
Uterine Tachysystole: Pain may be present but is typically related to frequent contractions rather than sharp, localized pain.
FHR Pattern
Abruptio Placentae: Commonly causes fetal heart rate abnormalities like late decelerations, bradycardia, or absent variability due to fetal hypoxia from compromised placental perfusion.
Uterine Tachysystole: Can cause decreased fetal heart rate variability and late decelerations because frequent contractions reduce oxygen delivery during inadequate relaxation.
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