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 ["A","C","D","E"]
Explanation
The correct answer is Choice A, Choice C, Choice D, Choice E.
Choice A rationale
Genetic counseling is recommended for couples concerned about birth defects to identify any potential genetic abnormalities or risks for inherited conditions.
Choice B rationale
Couples excited about having children do not necessarily require genetic counseling unless there are known risk factors or concerns about genetic conditions.
Choice C rationale
Loss of an embryo following an in-vitro fertilization procedure may indicate underlying genetic issues, warranting further evaluation through genetic counseling.
Choice D rationale
Huntington’s disease is an autosomal dominant disorder; individuals with a family history should seek genetic counseling to assess their risk of inheritance and possible transmission.
Choice E rationale
In-vitro fertilization with donated sperm may involve genetic screening and counseling to ensure the donor's genetic profile is compatible and free of heritable conditions.
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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