During a prenatal visit, a client at 30 weeks gestation reports persistent heartburn during the past two weeks.
The nurse notes the client has 3+ bilateral, pitting, pedal edema.
Which action should the nurse implement?

Explain that heartburn is a common discomfort.

Ask if blurred vision and headache have occurred.

Check urine for presence of glucose and ketones.

Instruct the client to take an antacid as needed.

Answer and Explanation

The Correct Answer is B

Choice A rationale

While heartburn is common during pregnancy due to hormonal changes and pressure from the growing uterus, the presence of 3+ bilateral pitting pedal edema raises concerns. This symptom could indicate a more serious condition, such as preeclampsia, and should not be dismissed as a normal discomfort.

Choice B rationale

Asking if blurred vision and headache have occurred is essential because these symptoms, along with significant edema, are indicators of preeclampsia. Preeclampsia is a serious pregnancy complication characterized by high blood pressure and damage to other organ systems, often requiring immediate medical attention.

Choice C rationale

Checking urine for glucose and ketones is relevant for assessing gestational diabetes but does not address the immediate concern of preeclampsia. The symptoms of edema and possible preeclampsia should be prioritized over concerns of gestational diabetes.

Choice D rationale

Instructing the client to take an antacid for heartburn does not address the critical issue of significant edema. While heartburn relief is important, the symptoms of edema need immediate evaluation to rule out preeclampsia or other complications.

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Correct Answer is D

Explanation

Choice D rationale

Low back pain with pelvic cramping can indicate complications such as premature labor or an infection after an amniocentesis.

Choice A rationale

Increased fetal movement is not typically a sign of complications following amniocentesis and may be a normal finding.

Choice B rationale

Headache and blurred vision are concerning symptoms but are not directly related to amniocentesis complications.

Choice C rationale

Epigastric pain can be a sign of other issues, such as preeclampsia, but not specifically related to amniocentesis complications. .

A. Bulb syringe use. B. Newborn screening tests. C. Techniques to breastfeed. D. Circumcision care.

Correct Answer is C

Explanation

Choice A rationale

While bulb syringe use is important for clearing the newborn's airways, it is not the immediate priority during the fourth stage of labor. This information can be provided later during routine newborn care education.

Choice B rationale

Newborn screening tests are important for identifying potential health issues, but the fourth stage of labor is focused on stabilizing the mother and infant and initiating breastfeeding. Screening information can be shared during the postpartum period.

Choice C rationale

Techniques to breastfeed are critical information to provide during the fourth stage of labor as it helps establish successful breastfeeding early on. This support can enhance maternal-infant bonding and promote breastfeeding success.

Choice D rationale

Circumcision care is relevant for parents who choose to circumcise their infant, but it is not the immediate priority during the fourth stage of labor. This information can be provided during subsequent postpartum visits.

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During a prenatal visit, a client at 30 weeks gestation reports persistent heartburn during the past two weeks.The nurse notes the client has 3+ bilateral, pitting, pedal edema.Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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During a prenatal visit, a client at 30 weeks gestation reports persistent heartburn during the past two weeks.
The nurse notes the client has 3+ bilateral, pitting, pedal edema.
Which action should the nurse implement?