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.
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Correct Answer is B
Explanation
Choice A rationale
Documenting the finding in the medical record is routine, but it does not address the potential concern of the fundal height discrepancy, which may indicate a need for further evaluation.
Choice B rationale
Scheduling a biophysical profile is crucial to assess the well-being of the fetuses, especially given the discrepancy in fundal height, which could indicate issues such as growth restriction or polyhydramnios.
Choice C rationale
Requesting another nurse to measure the fundus might help verify the measurement but does not address the potential underlying issue, which requires further assessment like a biophysical profile.
Choice D rationale
Notifying the healthcare provider is necessary, but it is more appropriate to first schedule a biophysical profile to gather comprehensive information on the fetal well-being before consulting the provider.
Correct Answer is D
Explanation
Choice A rationale
Obtaining a blood sample for complete blood count is crucial but secondary. The client’s low blood pressure and high heart rate indicate possible hypovolemia requiring immediate intervention to restore blood pressure and perfusion.
Choice B rationale
Infusing normal saline helps restore blood volume. However, it won't address supine hypotension syndrome, caused by uterine compression of the inferior vena cava, which necessitates repositioning the client first to improve hemodynamic stability.
Choice C rationale
Palpating the abdomen for contractions is important in assessing labor progress. Yet, it doesn't address the immediate hemodynamic instability caused by supine hypotension, which needs immediate correction to avoid fetal compromise.
Choice D rationale
Tilting the backboard laterally displaces the uterus off the inferior vena cava, alleviating supine hypotension syndrome. This improves maternal blood pressure and fetal perfusion, addressing the immediate hemodynamic instability effectively.
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