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 A
Explanation
Choice A rationale:
Advising the caller to take his wife to the nearest emergency room for evaluation is the appropriate response. The new mom's symptoms, including confusion and auditory hallucinations (conversations with herself), are indicative of a serious mental health condition. These symptoms could be caused by postpartum psychosis, a rare but severe form of postpartum depression. Postpartum psychosis requires immediate medical attention and hospitalization for the safety of both the mother and the baby. It is essential to rule out any potential medical causes and provide appropriate psychiatric evaluation and treatment in an emergency setting.
Choice B rationale:
Bringing the wife to the office for medication is not appropriate in this situation. The symptoms described by the baby's father are severe and require urgent evaluation in an emergency room. Medication management should only be initiated after a comprehensive psychiatric evaluation, which can be conducted in an emergency room setting.
Choice C rationale:
Suggesting outpatient care is not appropriate in this case. The severity of the symptoms, including confusion and hallucinations, indicates the need for immediate evaluation in an emergency setting. Outpatient care is not sufficient for addressing acute psychiatric emergencies.
Choice D rationale:
Recommending behavioral therapy is not appropriate for a situation involving acute confusion and hallucinations. Behavioral therapy is a valuable treatment for various mental health conditions, but it is not the appropriate intervention for acute symptoms like those described in this scenario.
Correct Answer is A
Explanation
Choice A rationale:
A respiratory rate of 10 bpm is significantly lower than the normal range for adults, which is typically 12-20 breaths per minute. This finding suggests respiratory depression, a potential complication of magnesium sulfate administration. Magnesium sulfate, when given intravenously, can lead to respiratory depression, hypotension, and loss of deep tendon reflexes. Monitoring respiratory rate is crucial to detect early signs of respiratory depression, allowing prompt intervention to prevent respiratory failure.
Choice B rationale:
A blood pressure of 148/94 mmHg is elevated and indicates hypertension. While hypertension is a known side effect of magnesium sulfate, a blood pressure reading alone is not specific enough to indicate a complication of treatment. It is essential to consider other vital signs and symptoms for a comprehensive assessment.
Choice C rationale:
Deep tendon reflexes of +2 are within the normal range and do not indicate a complication of magnesium sulfate administration. Hyperreflexia (exaggerated reflexes) is a sign of magnesium toxicity, but +2 reflexes are normal. Monitoring deep tendon reflexes is crucial, but the given value is within the normal range.
Choice D rationale:
An urine output of 70 ml/hour is within the normal range of urine output (30-60 ml/hour) for adults. While monitoring urine output is essential to assess renal function, this value does not indicate a complication of magnesium sulfate administration. Decreased urine output could suggest kidney injury, which is a potential complication of magnesium sulfate, but 70 ml/hour is within the normal range.
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