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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale

Notifying child protective services without further assessment may cause unnecessary distress and legal complications. The client's current alcohol use reduction efforts should be considered, and other interventions can be explored first.

Choice B rationale

Praising the client for reducing alcohol intake encourages positive behavior. Providing support and discussing ways to further decrease consumption promotes a collaborative approach to reducing alcohol exposure during pregnancy.

Choice C rationale

Disulfiram therapy is not suitable for pregnant clients due to potential risks. Instead, referral to an outpatient alcohol abuse program for counseling and support is more appropriate and safer for both mother and fetus.

Choice D rationale

Insisting on complete alcohol cessation without providing support may result in non-compliance. Drawing blood alcohol levels at each visit may cause anxiety and is not a practical approach for monitoring alcohol use in pregnancy.

Correct Answer is ["36"]

Explanation

Step 1 is: Convert 10 units to milliunits: 10 units × 1,000 milliunits/unit = 10,000 milliunits.

Step 2 is: Calculate the infusion rate: (6 milliunits/min ÷ 10,000 milliunits) × 1,000 mL = 0.6 mL/min.

Step 3 is: Convert the infusion rate to mL/hour: 0.6 mL/min × 60 min/hour = 36 mL/hour. Final calculated answer: 36 mL/hour.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client at 9 weeks gestation tells the nurse that while she has cut down, she still has at least one alcoholic drink every evening before bedtime. Which intervention should the nurse implement?

Correct Answer is B

Explanation

A client in active labor receives a prescription for oxytocin 6 milliunits/minute intravenously (IV). The IV bag contains oxytocin 10 units in lactated Ringer’s 1,000 mL. How many mL/hour should the nurse program the infusion pump to deliver? (Enter numerical value only.)

Correct Answer is ["36"]

Explanation

A nurse is caring for a 24-year-old pregnant woman in the prenatal clinic. She is gravida 2, para 1 (G2P1), and her mother has a history of type 2 diabetes mellitus. Exhibits: Exhibits Which is likely causing this client's increased blood glucose at 28 weeks? Select all that apply.

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The nurse knows that hydralazine, while magnesium sulfate will help prevent seizures, will help decrease blood pressure thus?

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