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 A
Explanation
Choice A rationale
A newborn’s heart rate normally varies between 120 and 160 beats per minute, but it can rise to 180 beats per minute when the infant is crying or drop as low as 80 to 90 beats per minute when in deep sleep. Therefore, an apical heart rate of 130/min is within the normal range for a newborn.
Choice B rationale
There is no need to call the provider for further assessment if the newborn’s heart rate is within the normal range.
Choice C rationale
Preparing the newborn for transport to the NICU is not necessary if the heart rate is within the normal range.
Choice D rationale
Asking another nurse to verify the heart rate is not necessary if the heart rate is within the normal range.
Correct Answer is B
Explanation
Choice A rationale
Low birth weight is defined as a birth weight of less than 2500 grams. This newborn weighs 3200 grams, so it does not fall into this category.
Choice B rationale
A newborn is considered appropriate for gestational age if its weight falls between the 10th and 90th percentile for its gestational age. This newborn’s weight is in the 60th percentile for its gestational age of 38 weeks, so it is appropriate for gestational age.
Choice C rationale
Large for gestational age refers to a newborn whose weight is above the 90th percentile for its gestational age. This newborn’s weight is in the 60th percentile, so it does not fall into this category.
Choice D rationale
Small for gestational age refers to a newborn whose weight is below the 10th percentile for its gestational age. This newborn’s weight is in the 60th percentile, so it does not fall into this category.
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