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
The vaginal contraceptive ring is designed for cyclic use, specifically to be left inserted for 3 consecutive weeks, followed by a 1-week ring-free interval. This regimen allows for a withdrawal bleed during the ring-free week, mimicking a natural menstrual cycle while maintaining contraceptive efficacy by providing continuous hormone release for 21 days.
Choice B rationale
Body weight fluctuations of 4.5 kg (10 lb) do not significantly impact the effectiveness of the vaginal contraceptive ring. The ring delivers a localized and consistent dose of hormones that is not dependent on systemic absorption influenced by minor weight changes. Therefore, contacting a provider for a new ring due to this weight change is unnecessary.
Choice C rationale
The vaginal contraceptive ring should not be washed with soap and water after each use. The ring is a single-use, disposable device designed to be inserted and remain in place for the full 3-week duration. Washing it could potentially degrade the material or interfere with the controlled release of hormones, compromising its efficacy.
Choice D rationale
The vaginal contraceptive ring does not need to be inserted immediately before sexual intercourse. It provides continuous contraceptive protection as long as it is inserted and used correctly according to the 3-week in, 1-week out schedule. Its efficacy is not tied to the timing of individual sexual acts.
Correct Answer is B
Explanation
Choice A rationale
Consuming 27 mg of iron daily is within the recommended intake for pregnant individuals, which is typically around 27 mg per day. Iron is crucial for fetal growth and preventing maternal anemia, and this intake level supports healthy pregnancy outcomes, indicating a reduced risk factor.
Choice B rationale
Consuming 300 mg of caffeine daily is considered a high-risk lifestyle factor during pregnancy. High caffeine intake is associated with an increased risk of miscarriage, preterm birth, and low birth weight infants. The recommended limit for pregnant individuals is generally below 200 mg per day to mitigate these risks.
Choice C rationale
Consuming 3 L (101 oz) of water daily is a healthy practice during pregnancy. Adequate hydration is essential for maintaining blood volume, amniotic fluid levels, and preventing constipation and urinary tract infections. This intake level supports maternal and fetal health.
Choice D rationale
Consuming 400 mcg of folate daily is the recommended intake for pregnant individuals, particularly in the periconceptional period. Folic acid supplementation significantly reduces the risk of neural tube defects in the fetus, promoting a healthy pregnancy outcome and indicating a reduced risk factor.
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