Nokea
A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider?
- A. Swelling of the face
- B. Varicose veins in the calves
- C. Nonpitting 1+ ankle edema
- D. Hyperpigmentation of the cheeks
Correct Answer: A
Rationale: The correct answer is A: Swelling of the face. This finding can indicate preeclampsia, a serious pregnancy complication characterized by high blood pressure and protein in the urine. Preeclampsia poses risks to both the mother and the baby, so prompt reporting to the provider is crucial for timely intervention. Varicose veins in the calves (B) are common in pregnancy due to increased pressure on the veins but do not require immediate provider notification. Nonpitting 1+ ankle edema (C) is a common finding in pregnancy and is not typically concerning unless it worsens significantly. Hyperpigmentation of the cheeks (D) is a common benign finding known as melasma and does not require immediate reporting unless accompanied by other concerning symptoms.
You may also like to solve these questions
A nurse is teaching a client who is at 35 weeks of gestation about manifestations of potential pregnancy complications to report to the provider. Which of the following manifestations should the nurse include?
- A. Shortness of breath when climbing stairs
- B. Swelling of feet and ankles at the end of the day
- C. Headache that is unrelieved by analgesia
- D. Braxton Hicks contractions
Correct Answer: C
Rationale: The correct answer is C: Headache that is unrelieved by analgesia. This symptom could indicate preeclampsia, a serious pregnancy complication characterized by high blood pressure and organ damage. Prompt reporting is crucial to prevent complications. Shortness of breath (A) and swelling of feet and ankles (B) are common in pregnancy but not necessarily indicative of a serious complication. Braxton Hicks contractions (D) are normal and not usually a cause for concern.
A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain?
- A. Decreased heart rate.
- B. Chin quivering.
- C. Pinpoint pupils.
- D. Slowed respirations.
Correct Answer: B
Rationale: The correct answer is B: Chin quivering. Pain assessment in newborns can be challenging due to their limited ability to communicate. Chin quivering is a nonverbal sign of pain in newborns. It indicates stress and discomfort. Decreased heart rate, pinpoint pupils, and slowed respirations are not reliable indicators of pain in newborns and may be attributed to other factors. Therefore, the nurse should identify chin quivering as a significant sign of pain in this scenario.
A nurse in a clinic is caring for a 16-year-old adolescent. Which of the following findings should the nurse report to the provider? (Select all that apply.)
- A. Abdominal assessment
- B. Vaginal discharge
- C. Heart rate
- D. Temperature
- E. Dyspareunia
- F. Condom usage
Correct Answer: A,B,D,E,F
Rationale: The correct answers to report to the provider are A, B, D, E, and F. A: Abdominal assessment is crucial to identify any potential underlying issues. B: Vaginal discharge in an adolescent may indicate infection or hormonal imbalance. D: Temperature abnormalities could signal infection. E: Dyspareunia (pain during intercourse) may indicate reproductive health concerns. F: Condom usage is important for safe sex practices. Choices C and G are not specifically related to the adolescent's care needs and do not require immediate reporting.
A nurse is teaching a client who is at 37 weeks of gestation and has a prescription for a nonstress test. Which of the following instructions should the nurse include?
- A. The test should take 10 to 15 minutes to complete.
- B. You will lie in a supine position throughout the test.
- C. You should not eat or drink for hours before the test.
- D. You should press the handheld button when you feel your baby move.
Correct Answer: D
Rationale: The correct answer is D: You should press the handheld button when you feel your baby move. In a nonstress test, the client is required to press a handheld button whenever they feel the baby move. This action helps to correlate fetal movements with changes in the fetal heart rate, allowing healthcare providers to assess the baby's well-being. This active participation from the client ensures accurate monitoring of the baby's condition. The other choices are incorrect because: A: The duration of a nonstress test can vary but typically takes around 20-40 minutes. B: Lying in a supine position is not recommended during pregnancy as it can decrease blood flow to the baby. C: It is important for the client to have a light meal before the test to ensure the baby is active during monitoring.
A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider?
- A. Acrocyanosis.
- B. Transient strabismus.
- C. Jaundice.
- D. Caput succedaneum.
Correct Answer: C
Rationale: The correct answer is C: Jaundice. Jaundice in a newborn within the first 24 hours may indicate pathological conditions such as hemolytic disease or liver dysfunction. It requires immediate evaluation and treatment. Acrocyanosis (A) is a common finding in newborns due to immature circulation. Transient strabismus (B) is often seen in newborns and typically resolves on its own. Caput succedaneum (D) is swelling on the newborn's scalp from pressure during birth, which is a normal finding.