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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Keeping the head of the bed at a 30-degree angle is not typically necessary following scoliosis repair with Harrington rod instrumentation. The position of the bed is usually determined by the patient’s comfort and the surgeon’s specific post-operative instructions.
Choice B rationale
Initiating the use of a PCA (Patient-Controlled Analgesia) pump for pain control is a common intervention following scoliosis repair with Harrington rod instrumentation. This allows the patient to self-administer pain medication as needed, providing effective and individualized pain control.
Choice C rationale
Repositioning the client by log rolling every 4 hours is a common practice after spinal surgery to prevent pressure ulcers and maintain alignment of the spine. However, it is not the primary intervention in this case.
Choice D rationale
Placing the client in protective isolation is not typically necessary following scoliosis repair with Harrington rod instrumentation. Isolation is usually reserved for patients who are at high risk of infection or who have an infection that could be transmitted to others.
Correct Answer is A
Explanation
Choice A rationale
Supporting the casted arm with a firm grasp is important to prevent unnecessary movement and potential discomfort or injury to the child. It also helps in ensuring the correct positioning of the cast.
Choice B rationale
Placing a heated fan at the bedside to facilitate drying is not recommended. Excessive heat can cause discomfort and potential burns to the child. The cast should be allowed to dry naturally.
Choice C rationale
Telling the child that the cast will make their arm feel better can be misleading. While the cast is necessary for healing, it may cause discomfort and itching. It’s important to explain to the child what the cast is for and what to expect.
Choice D rationale
Wrapping the arm of the child’s doll or toy prior to the procedure can help the child understand what is happening and make them feel more comfortable. However, this action alone is not sufficient in preparing to apply a cast to a preschooler’s arm.
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