A nurse is collecting data from a client who is at 29 weeks of gestation.
Which of the following findings should the nurse identify as a potential indication of a prenatal complication?
Leg cramps.
Ptyalism.
Blurred vision.
Melasma.
The Correct Answer is C
This can be a sign of preeclampsia, a serious complication of pregnancy that causes high blood pressure and proteinuria.
The nurse should report this finding to the provider and monitor the client’s blood pressure, urine protein, and reflexes.
Choice A is wrong because leg cramps are a common discomfort during pregnancy and are not usually a sign of a complication.
Choice B is wrong because ptyalism, or excessive salivation, is a normal physiological change during pregnancy and does not indicate a problem.
Choice D is wrong because melasma, or darkening of the skin on the face, is also a normal physiological change during pregnancy and does not pose a risk to the mother or the fetus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Clean the cannula prongs daily.
This is because the nasal cannula can become contaminated with bacteria and mucus, which can cause infection and irritation of the nasal mucosa. Cleaning the cannula prongs daily with soap and water can prevent these complications.
Choice A is wrong because humidifiers can help moisten the dry oxygen and prevent nasal dryness and bleeding. Humidifiers should be used for oxygen flow rates higher than 4 L/min.
Choice B is wrong because the cannula prongs should be positioned curving downward in the nose, not upward. This allows for better alignment with the natural direction of airflow and reduces the risk of dislodgement.
Choice D is wrong because keeping the oxygen tubing off the floor is not a specific action for nasal cannula use. It is a general safety measure to prevent tripping and contamination of the tubing.
Correct Answer is B
Explanation
The nurse should begin discharge planning upon the client’s admission. This is because discharge planning is a key aspect of effective care that reduces the length of stay, emergency readmissions and pressure on hospital beds. Discharge planning involves considering what support might be required by the client in the community, referring the client to these services, and liaising with these services to manage the client’s discharge.
Choice A is wrong because the nurse is not responsible for providing a written prescription for a client home care referral. This is the role of the provider or another authorised prescriber.
Choice C is wrong because a home hazard appraisal does not include an assessment of the client’s financial resources. A home hazard appraisal is an evaluation of the safety and accessibility of the client’s home environment.
Choice D is wrong because a medication reconciliation is not required 24 hours prior to the client’s discharge. A medication reconciliation is a process of comparing the medications a client is taking with those prescribed for them to avoid errors or discrepancies. A medication reconciliation should be done at every transition of care, including admission, transfer and discharge.
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