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 B
Explanation
The correct answer is choiceb. Fetal movement palpated by the nurse-midwife.
Choice A rationale:
A positive pregnancy test is considered a probable sign of pregnancy, not a positive sign. Probable signs are those that strongly suggest pregnancy but are not definitive.
Choice B rationale:
Fetal movement palpated by the nurse-midwife is a positive sign of pregnancy. Positive signs are those that provide definitive evidence of pregnancy, such as fetal heart tones heard by a Doppler device or ultrasound visualization of the fetus.
Choice C rationale:
Braxton Hicks contractions are considered a probable sign of pregnancy. These are irregular, painless contractions that can occur throughout pregnancy but do not confirm pregnancy definitively.
Choice D rationale:
Quickening, or the first feeling of fetal movement by the mother, is a presumptive sign of pregnancy. Presumptive signs are those that the woman experiences and reports, which may suggest pregnancy but are not conclusive.
Correct Answer is C
Explanation
Choice A rationale:
A stat magnesium sulfate level (Choice A) is unnecessary in this situation. The symptoms described - increased temperature, pulse rate, and blood pressure, along with absent deep tendon reflexes - indicate magnesium sulfate toxicity. Discontinuing the infusion and managing the symptoms take precedence over checking the magnesium sulfate level.
Choice B rationale:
Administering oxygen (Choice B) is important for maintaining the patient's oxygenation levels, but it does not address the magnesium sulfate toxicity. The primary intervention should be to discontinue the infusion and manage the symptoms.
Choice C rationale:
Discontinuing the magnesium sulfate infusion (Choice C) is the correct action in this situation. The symptoms, including absent deep tendon reflexes and the patient's complaint of thirst and warmth, indicate magnesium sulfate toxicity. Stopping the infusion is crucial to prevent further complications.
Choice D rationale:
Hydralazine (Choice D) is an antihypertensive medication and is not the appropriate intervention for magnesium sulfate toxicity. Managing magnesium sulfate toxicity involves discontinuing the infusion and providing supportive care.
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