A nurse is caring for a pregnant client and reviewing signs of complications that should be promptly reported to the provider.

Which of the following should be included?

Vaginal bleeding.

Lightheadedness when lying on back.

Heartburn after eating.

Swelling of the ankles.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Vaginal bleeding during pregnancy can be a sign of a serious complication such as placenta previa or placental abruption. Placenta previa is a condition where the placenta partially or completely covers the cervix, which can lead to severe bleeding during pregnancy and delivery. Placental abruption is a serious condition in which the placenta separates from the uterus before the baby is born, which can cause heavy bleeding and can be life-threatening for both the mother and the baby. Therefore, any vaginal bleeding during pregnancy should be promptly reported to the healthcare provider.
Choice B rationale
Lightheadedness when lying on the back, also known as supine hypotensive syndrome, can occur in pregnancy when the enlarged uterus compresses the inferior vena cava, reducing blood return to the heart and causing a drop in blood pressure. While this can be uncomfortable, it is generally not considered a serious complication and can be alleviated by changing position.
Choice C rationale
Heartburn after eating is a common discomfort during pregnancy due to hormonal changes that relax the lower esophageal sphincter, allowing stomach acid to reflux into the esophagus. While it can be uncomfortable, it is generally not a sign of a serious complication.
Choice D rationale
Swelling of the ankles, also known as edema, is common in pregnancy due to increased fluid volume in the body. While it can be uncomfortable, it is generally not a sign of a serious complication unless it is sudden or severe, which could be a sign of preeclampsia.

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Correct Answer is ["C","D","E"]

Explanation

Choice A rationale
A newborn born at 32 weeks of gestation and weighing 1,100 g is considered preterm and is likely to have a thin, fragile appearance rather than a plump face.
Choice B rationale
Dehydration is not a typical finding in a preterm newborn unless there are underlying health issues or complications.
Choice C rationale
Long nails are a common finding in preterm newborns. This is because nail growth begins in the womb and preterm babies have had less time to wear down their nails through movement.
Choice D rationale
A weak grasp reflex is common in preterm newborns. This is due to their immature nervous system.
Choice E rationale
The presence of lanugo, or fine hair, is common in preterm newborns. Lanugo usually begins to disappear around 32 weeks of gestation, so a baby born at this time may still have a significant amount.

A. Apply pressure dressing four hours after discharge. B. Call the provider if the patient’s leg feels cool to touch compared to the left extremity. C. Administer acetaminophen or ibuprofen oral solution if needed for pain. D. Maintain a clear liquid diet for 24 hours after discharge.

Correct Answer is C

Explanation

Choice A rationale
Applying a pressure dressing four hours after discharge is not typically recommended following a cardiac catheterization. The site of the catheter insertion is usually covered with a simple dressing and observed for any signs of bleeding or swelling.
Choice B rationale
While it’s important to monitor for signs of impaired circulation, such as a cool extremity, this is not the primary concern following a cardiac catheterization. The procedure involves inserting a catheter into a blood vessel, not typically affecting the peripheral temperature of the extremities.
Choice C rationale
Administering acetaminophen or ibuprofen for pain as needed is a common recommendation following procedures like a balloon angioplasty. Pain can result from the catheter insertion site and these medications can help manage it.
Choice D rationale
Maintaining a clear liquid diet for 24 hours after discharge is not typically necessary following a cardiac catheterization. Once the child is alert, they are usually provided with clear liquids and later something to eat.

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A nurse is caring for a pregnant client and reviewing signs of complications that should be promptly reported to the provider. Which of the following should be included?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the assessment of a newborn who was born at 32 weeks of gestation. The newborn’s birth weight is 1,100 g. What are the expected findings in this newborn? (Select all that apply.)

Correct Answer is ["C","D","E"]

Explanation

A nurse is providing care for a 6-month-old infant who underwent a cardiac catheterization. The child was diagnosed with pulmonary stenosis early in infancy and was admitted today for a balloon angioplasty procedure. Which of the following should the nurse plan to include in the discharge teaching?

Correct Answer is C

Explanation

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A nurse is caring for a pregnant client and reviewing signs of complications that should be promptly reported to the provider.

Which of the following should be included?