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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Abdominal respirations do not directly predispose toddlers to frequent infections such as otitis media, tonsillitis, and upper respiratory tract infections. Abdominal respirations are a normal breathing pattern in toddlers, transitioning from the diaphragmatic breathing seen in infants. This change is due to the toddler's increased chest wall compliance and stronger intercostal muscles, facilitating more efficient breathing.
Choice B rationale:
Slower pulse and respiratory rates in toddlers compared to infants are part of normal physiological development. Toddler's heart rates range from 70 to 110 beats per minute, and respiratory rates range from 20 to 30 breaths per minute. These rates are considered normal for toddlers and do not predispose them to frequent infections.
Choice C rationale:
Toddlers do have less efficient defense mechanisms than infants, making them more susceptible to infections. This is due to the immature immune system in toddlers, which is still developing and learning to respond to various pathogens. However, this choice is not the most important factor predisposing toddlers to frequent infections; other factors play a more significant role.
Choice D rationale:
The presence of short, straight internal ear/throat structures and large tonsil/adenoid lymph tissue in toddlers is the most important factor predisposing them to frequent infections such as otitis media, tonsillitis, and upper respiratory tract infections. These anatomical features make it easier for bacteria and viruses to enter and infect the respiratory and ear passages, leading to recurrent infections.
Correct Answer is D
Explanation
This question evaluates the nurse's understanding of neonatal assessment protocols using the Apgar scoring system. One must differentiate between the immediate clinical interpretation of a perfect score and the mandatory requirement for follow-up assessment to ensure sustained transition to extrauterine life.
Choice A rationale: While a score of 10 indicates the infant has transitioned well, standard protocol mandates a follow-up assessment. One score does not preclude the need for monitoring, as neonatal status can change rapidly following the initial adjustment to the outside environment.
Choice B rationale: An Apgar score of 10 is the highest possible score, indicating the infant is in excellent condition. Severe distress is associated with low scores ranging from 0 to 3, which would necessitate immediate, aggressive resuscitation interventions by the medical team.
Choice C rationale: The Apgar score is a rapid assessment tool for immediate physiological transition and is not a prognostic indicator for long-term neurological development. Attributing future neurological status to a 1-minute score is clinically inaccurate and unsupported by research on neonatal outcomes.
Choice D rationale: An Apgar score of 10 at 1 minute demonstrates that the newborn is adjusting excellently to extrauterine life. However, hospital protocol requires a secondary assessment at 5 minutes to confirm stable adaptation and ensure no delayed signs of respiratory or cardiovascular compromise emerge.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.