At a prenatal visit at 36 weeks' gestation, a client complains of discomfort with irregularly occurring contractions (Braxton Hicks contractions). The nurse instructs the client to:
Walk around and increase fluid intake.
Time contractions for 30 minutes.
Take aspirin for the discomfort.
Go to the hospital.
The Correct Answer is A
Choice A rationale
Walking and increasing fluid intake can often alleviate the discomfort associated with Braxton Hicks contractions. Movement can sometimes cause the uterus to relax, and adequate hydration helps maintain uterine irritability within normal physiological limits. Dehydration can sometimes exacerbate uterine contractions, so ensuring sufficient fluid intake is a prudent measure.
Choice B rationale
Timing contractions is more relevant when assessing for true labor. Braxton Hicks contractions are irregular and do not follow a consistent pattern of increasing frequency, duration, and intensity. Instructing the client to time them for 30 minutes may cause unnecessary anxiety and is not the primary intervention for discomfort relief.
Choice C rationale
Aspirin is not recommended during pregnancy, especially in the third trimester, due to potential risks to both the mother and the fetus, such as increased bleeding tendencies. Furthermore, aspirin would not address the physiological cause of Braxton Hicks contractions.
Choice D rationale
Going to the hospital is not indicated for irregular, non-painful Braxton Hicks contractions, especially at 36 weeks' gestation. Hospital visits are reserved for signs of true labor, such as regular, increasing contractions, rupture of membranes, or significant bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
A urinary output of 30 mL/hr is within the normal range for an adult, indicating adequate kidney perfusion and hydration status postpartum. Normal urine output is typically considered to be greater than 30 mL/hr.
Choice B rationale
Headache pain rated a 6 on a scale of 0 to 10 is a common complaint postpartum, especially after spinal anesthesia. While it requires assessment and management, it is not necessarily a sign of immediate life-threatening complication. Postpartum headaches can be related to hormonal shifts, dehydration, or the spinal anesthesia itself.
Choice C rationale
A blood pressure of 100/70 mm Hg is within the normal postpartum range for many women. While a decrease from pre-pregnancy levels can occur, this reading does not indicate an immediate critical issue. Normal postpartum blood pressure generally stabilizes around pre-pregnancy levels within a few days.
Choice D rationale
A respiratory rate of 10 breaths per minute is below the normal adult range of 12 to 20 breaths per minute. This bradypnea could indicate respiratory depression, a potential complication of spinal anesthesia, especially if opioid analgesics have been administered. Immediate intervention is required to assess the cause and ensure adequate oxygenation.
Correct Answer is B
Explanation
Choice A rationale
A glucose reading of 58 mg/dL in a newborn is below the normal range (typically 40-60 mg/dL in the first hours of life, rising to 50-90 mg/dL). While it requires attention and intervention to prevent hypoglycemia, it is not as immediately life-threatening as a significantly low temperature.
Choice B rationale
A temperature of 97.4°F (36.3°C) in a newborn is below the normal range (typically 97.7°F to 99.5°F or 36.5°C to 37.5°C). Hypothermia in a newborn can lead to cold stress, increased oxygen consumption, and hypoglycemia. This newborn needs immediate assessment and warming measures to prevent complications.
Choice C rationale
A respiratory rate of 48 breaths per minute is within the normal range for a newborn (typically 30-60 breaths per minute). While the nurse will continue to monitor the respiratory status, this finding does not indicate immediate distress.
Choice D rationale
A pulse rate of 134 beats per minute is within the normal range for a newborn (typically 110-160 beats per minute). While the nurse will continue to monitor the cardiovascular status, this finding does not indicate immediate distress. .
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.