A client in the third trimester of pregnancy is troubled by frequent nasal stuffiness and occasional nosebleeds. Her chest circumference has increased by 5 cm during the pregnancy, and she uses thoracic breathing. Her diaphragm is elevated and she has an increased costal angle. Which intervention should the nurse implement?
Ask a nurse with more experience to validate the costal angle finding.
Examine the client for signs of tissue anoxia, such as pallor.
Ask the healthcare provider to evaluate the client’s respiratory status.
Record the respiratory finding in the client’s record as normal.
The Correct Answer is D
Choice A rationale
Asking another nurse to validate the costal angle finding is unnecessary, as the increased costal angle is a common physiological change during pregnancy due to the expanding uterus.
Choice B rationale
Examining for tissue anoxia, such as pallor, is not relevant in this scenario, as the nasal stuffiness and nosebleeds are likely due to increased blood volume and hormonal changes in pregnancy.
Choice C rationale
Requesting the healthcare provider to evaluate the client's respiratory status is unwarranted, as the described symptoms are typical physiological adaptations during pregnancy and not indicative of respiratory pathology.
Choice D rationale
Documenting the respiratory finding as normal is appropriate, as the increased chest circumference, thoracic breathing, elevated diaphragm, and increased costal angle are expected physiological changes during pregnancy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Caput succedaneum is a benign swelling of the soft tissues of the scalp that crosses suture lines and does not require drainage.
Choice B rationale
Cephalhematoma is a collection of blood between the skull and periosteum that does not cross suture lines; it may contribute to jaundice as it is reabsorbed by the body.
Choice C rationale
While cephalhematoma usually resolves without intervention, it is important to monitor for potential complications, including jaundice, due to the breakdown of red blood cells.
Choice D rationale
Caput succedaneum typically resolves on its own without intervention, as the fluid is gradually absorbed by the body over time.
Correct Answer is A
Explanation
Choice A rationale
Hydralazine decreases blood pressure by vasodilation, improving renal perfusion and function. Enhanced kidney function promotes diuresis, balancing fluid levels and reducing hypertension.
Choice B rationale
While controlling blood pressure indirectly benefits liver health, hydralazine's primary effect on vasodilation does not directly support liver function.
Choice C rationale
Hydralazine primarily lowers blood pressure through vasodilation. Preventing arrhythmias is more directly associated with medications affecting cardiac conduction rather than vasodilators.
Choice D rationale
Lowering cholesterol levels is not a direct effect of hydralazine. Its primary action is reducing blood pressure through vascular smooth muscle relaxation, decreasing hypertension.
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