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 C

Explanation

Choice A rationale

Administering the rubella vaccine after 20-weeks gestation is inappropriate as it is a live vaccine, which poses potential risks to the fetus. The vaccine is contraindicated during pregnancy due to teratogenic effects.

Choice B rationale

Administering the rubella vaccine at 6-weeks gestation is contraindicated because it is a live vaccine. Live vaccines pose risks to the fetus and are not recommended during pregnancy due to potential teratogenicity.

Choice C rationale

Administering the rubella vaccine early postpartum within 72 hours after delivery is recommended. This timing ensures the mother is not pregnant and reduces the risk of congenital rubella syndrome in future pregnancies.

Choice D rationale

Waiting until the client stops breastfeeding is unnecessary. The rubella vaccine can be safely administered during breastfeeding, as it does not pose a risk to the infant or affect milk production.

A. Fetal health problems B. Decreased cortisol C. Increased insulin needs D. Placental infection E. Normal weight gain of pregnancy F. Fetus with macrosomia

Correct Answer is ["C","E","F"]

Explanation

Choice A rationale: Fetal health problems are not directly linked to maternal blood glucose levels. The fetus relies on maternal glucose, but fetal health issues do not cause maternal hyperglycemia.

Choice B rationale: Decreased cortisol is unlikely to cause increased blood glucose levels. Cortisol typically raises blood glucose by promoting gluconeogenesis and decreasing glucose uptake by cells.

Choice C rationale: Increased insulin needs during pregnancy are due to insulin resistance caused by placental hormones. This physiological change ensures adequate glucose supply to the fetus, leading to higher maternal blood glucose levels.

Choice D rationale: Placental infection can cause inflammation and other complications but is not a common cause of increased blood glucose levels. Infections typically present with fever and other systemic symptoms.

Choice E rationale: Normal weight gain during pregnancy can contribute to insulin resistance. Increased adipose tissue leads to higher levels of circulating free fatty acids, which impair insulin signaling and glucose uptake.

Choice F rationale: A fetus with macrosomia is often associated with maternal hyperglycemia. Excess glucose crosses the placenta, stimulating fetal insulin production and growth, leading to larger fetal size.

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Naxlex Comprehensive Predictor Exams

When is the best time to administer a rubella vaccine to a client?

Correct Answer is C

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.

Correct Answer is ["C","E","F"]

Explanation

The nurse is reviewing the prescriptions to determine priorities. Which prescriptions take priority?

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