A woman is in her seventh month of pregnancy.
She has been reporting nasal congestion and occasional epistaxis.
The nurse suspects that.

this is a normal respiratory change in pregnancy caused by elevated levels of estrogen.

this is an abnormal cardiovascular change, and the nosebleeds are an ominous sign.

the woman is a victim of domestic violence and is being hit in the face by her partner.

the woman has been using cocaine intranasally.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Nasal congestion and occasional epistaxis (nosebleeds) are common symptoms during pregnancy due to elevated levels of estrogen. Increased estrogen causes mucosal blood vessels to become engorged and more fragile, leading to nasal congestion and occasional nosebleeds. This is a normal respiratory change in pregnancy and not necessarily a cause for concern.

Choice B rationale:

While cardiovascular changes are common in pregnancy, nosebleeds alone are not indicative of abnormal cardiovascular changes unless they are accompanied by other symptoms. The given scenario does not provide enough information to support this choice.

Choice C rationale:

There is no evidence provided to suggest domestic violence (Choice C) as the cause of the woman's symptoms. Additionally, this choice lacks a physiological basis for the symptoms described.

Choice D rationale:

Intranasal cocaine use (Choice D) can indeed cause nasal congestion and frequent nosebleeds. However, the scenario does not provide any information to support this choice, and assuming drug use without evidence is not appropriate.

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Correct Answer is A

Explanation

Choice A rationale:
Weighing the infant every day on the same scale at the same time is crucial in monitoring excess fluid volume in congestive heart failure. Sudden weight gain can indicate fluid retention, a common sign of worsening heart failure. Daily weight monitoring helps in early detection and timely intervention.
Choice B rationale:
Notifying the physician when weight gain exceeds more than 20 g/day might be too late for intervention. Daily weight monitoring is essential to detect trends and intervene promptly to manage excess fluid volume.
Choice C rationale:
Placing the infant in a car seat to minimize movement is not directly related to managing excess fluid volume in congestive heart failure. It is essential for safety during transportation but does not address the nursing diagnosis.
Choice D rationale:
Administering digoxin as ordered by the physician is a medical intervention for congestive heart failure. While important, the nursing diagnosis is related to excess fluid volume, and the focus should be on nursing interventions such as monitoring daily weights.

A. only in the third trimester from the maternal circulation. B. by a needlestick injury at birth from unsterile instruments. C. only through the ingestion of amniotic fluid. D. through the ingestion of breast milk from an infected mother.

Correct Answer is D

Explanation

Choice A rationale:

Perinatal transmission of HIV can occur not only in the third trimester but also during labor and delivery. It is not limited to the maternal circulation alone.

Choice B rationale:

While needlestick injuries are a potential risk for healthcare workers, perinatal transmission to the newborn does not occur through this route.

Choice C rationale:

HIV is not transmitted through the ingestion of amniotic fluid. The virus can be present in the amniotic fluid, but the main route of transmission to the newborn is during delivery or through breastfeeding.

Choice D rationale:

The correct answer. HIV can be transmitted from an infected mother to her child through breastfeeding if appropriate antiretroviral therapy is not administered. Breast milk can contain the virus, putting the infant at risk of infection. Therefore, in cases where the mother is HIV-positive, formula feeding is recommended to prevent transmission of the virus to the newborn.

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A woman is in her seventh month of pregnancy.She has been reporting nasal congestion and occasional epistaxis.The nurse suspects that.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which intervention should be included in the plan of care for an infant with the nursing diagnosis of Excess Fluid Volume related to congestive heart failure?

Correct Answer is A

Explanation

Human immunodeficiency virus (HIV) may be perinatally transmitted.

Correct Answer is D

Explanation

What should the nurse stress in a teaching plan for the mother of an 11-year-old diagnosed with ulcerative colitis?

The nurse should teach a pregnant woman that which substances are teratogens? (Select all that apply.).

The nurse is meeting a 5-year-old child for the first time and would like the child to cooperate during a dressing change. The nurse decides to do a simple magic trick using gauze. This should be interpreted as:

What is an important nursing responsibility when dealing with a family experiencing the loss of an infant from sudden infant death syndrome (SIDS)?

The nurse administers vitamin K to the newborn for which reason?

During the preconception phase, the nurse should teach about which infectious diseases as risk factors for maternal complications? (Select all that apply).

A woman is in her seventh month of pregnancy.
She has been reporting nasal congestion and occasional epistaxis.
The nurse suspects that.