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 B
Explanation
Choice A rationale
Documenting the finding without further action is inappropriate when faced with an abnormal FHR pattern. Immediate intervention is crucial to prevent potential fetal hypoxia or distress, necessitating a prompt response.
Choice B rationale
Notifying the healthcare provider is essential when encountering abnormal FHR patterns. Timely communication allows for appropriate interventions to be implemented, reducing the risk of adverse fetal outcomes and ensuring patient safety.
Choice C rationale
Scheduling an ultrasound is not the immediate priority when an abnormal FHR pattern is detected. Immediate clinical evaluation and interventions are necessary to address potential fetal distress or hypoxia.
Choice D rationale
Obtaining a hematocrit level is unrelated to the immediate management of abnormal FHR patterns. The priority is to address the fetal well-being and ensure adequate oxygenation through timely clinical interventions.
Correct Answer is ["A","B","D","E"]
Explanation
Choice A rationale
Acidemia in the fetus can result from abnormal fetal heart rate (FHR) patterns. It is indicative of hypoxia and inadequate oxygenation, leading to anaerobic metabolism and accumulation of lactic acid in fetal tissues.
Choice B rationale
Hypoxia can occur due to abnormal FHR patterns. Hypoxia results from insufficient oxygen supply to the fetus, which can lead to metabolic acidosis, impaired organ function, and potential long-term developmental issues.
Choice C rationale
Hypoglycemia is not directly related to abnormal FHR patterns. It is primarily associated with metabolic disturbances such as inadequate glucose supply or insulin regulation in the neonate or fetus.
Choice D rationale
Meconium stool passage can result from fetal hypoxia due to abnormal FHR patterns. Hypoxia increases gastrointestinal peristalsis, leading to the release of meconium into the amniotic fluid, which poses a risk for aspiration.
Choice E rationale
Maternal hypotension can lead to abnormal FHR patterns. Hypotension reduces uteroplacental blood flow, leading to fetal hypoxia and compromised oxygen delivery to the fetus, which can result in fetal distress.
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