The nurse provides a 16-year-old client with information concerning expected and possible changes during pregnancy.
Which statement, if made by the client, would indicate that she understands the information?
“I should expect a few spots of blood on my underwear because I have more blood in my body now.”.
“Clear fluid will leak from my vagina if my baby is surrounded by too much water in my womb.”.
“If I begin to see dark patches on my face, it means that my blood pressure is rising.”.
“If I feel like I have butterflies in my stomach, it means my baby is moving.”.
The Correct Answer is D
The correct answer is choice D. If the client feels like she has butterflies in her stomach, it means her baby is moving.
This is a normal and expected change during pregnancy, especially in the second and third trimesters. The baby’s movements can be felt as flutters, kicks, or rolls.
Choice A is wrong because spotting of blood on the underwear is not a normal change during pregnancy.
It can indicate a problem such as placenta previa, placental abruption, or miscarriage. Any bleeding during pregnancy should be reported to the health care provider.
Choice B is wrong because clear fluid leaking from the vagina is not a normal change during pregnancy.
It can indicate that the membranes have ruptured and amniotic fluid is escaping.
This can lead to infection and preterm labor if not treated promptly. Any fluid leakage during pregnancy should be reported to the health care provider.
Choice C is wrong because dark patches on the face are not a sign of high blood pressure during pregnancy.
They are called melasma or chloasma and are caused by increased pigmentation due to hormonal changes. They usually fade after delivery and are not harmful. High blood pressure during pregnancy can cause symptoms such as headache, blurred vision, swelling, and protein in the urine.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This is because the first priority for a pregnant woman with acute abdominal pain is to assess the fetal well-being and rule out any obstetric complications such as placental abruption, uterine rupture, or preterm labor.Fetal heart tones can indicate the presence and viability of the fetus and alert the nurse to any signs of fetal distress or hypoxia.
Choice A: Obtain a full history is wrong because it is not the most urgent action.
A full history can provide valuable information about the possible causes of abdominal pain, but it should not delay the assessment of fetal status and maternal vital signs.
Choice B: Examine the cervix for dilation is wrong because it can be harmful in some cases.A digital cervical examination should be avoided until placenta previa is ruled out by ultrasound, as it can cause bleeding and worsen the condition.
Moreover, cervical dilation alone does not indicate the cause or severity of abdominal pain.
Choice D: Palpate for uterine contraction frequency is wrong because it is not the most reliable method to assess labor.Uterine contractions can be measured by external tocodynamometry or internal intrauterine pressure catheter, which can provide more accurate and objective data than manual palpation.
Furthermore, uterine contractions do not necessarily indicate labor, as they can also be caused by other conditions such as dehydration, infection, or irritable uterus.
Correct Answer is D
Explanation
he correct answer is choice D. Keep the infant well hydrated.This is because phototherapy can cause dehydration due to increased insensible water loss from the skin.Hydration helps the infant excrete bilirubin in urine and stool.
Choice A is wrong because elevating the head of the infant’s crib does not affect bilirubin levels or phototherapy effectiveness.
Choice B is wrong because applying a water-soluble ointment to the infant’s eyes can interfere with eye protection and cause eye irritation.The infant’s eyes should be covered with opaque patches or goggles during phototherapy to prevent eye damage.
Choice C is wrong because dressing the infant in a long-sleeved shirt reduces the amount of skin exposed to light and decreases the efficacy of phototherapy.The infant should be undressed except for a diaper and eye protection during phototherapy.
Normal ranges for bilirubin levels vary depending on the age of the infant, the type of jaundice, and the method of measurement.Generally, bilirubin levels above 25 mg/dL are considered dangerous and require urgent treatment.
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