A nurse collecting data on a client who is 38 weeks of gestation during a weekly prenatal visit.
Which of the following findings should the nurse report to the provider?
Report of insomnia.
Blood-tinged mucous vaginal discharge.
Blood pressure 134/80 mm Hg.
Weight gain of 2.2 kg (4.8 lbs).
The Correct Answer is D
Choice A rationale
Report of insomnia is a common and often expected complaint during the third trimester of pregnancy due to physical discomforts such as frequent urination, fetal movement, and difficulty finding a comfortable position. While bothersome for the client, it is typically not indicative of a serious complication requiring immediate reporting to the provider in a routine prenatal visit.
Choice B rationale
Blood-tinged mucous vaginal discharge, or "bloody show," is a normal finding at 38 weeks of gestation. It indicates cervical changes such as effacement and dilation as the body prepares for labor. This physiological process results from the rupture of small capillaries in the cervix and is expected.
Choice C rationale
A blood pressure of 134/80 mm Hg, while slightly elevated from typical mid-pregnancy readings, is generally within acceptable limits for a 38-week gestation. A normal blood pressure range in pregnancy is typically less than 140/90 mm Hg. This reading alone does not indicate preeclampsia or other hypertensive disorders in the absence of other symptoms.
Choice D rationale
A weight gain of 2.2 kg (4.8 lbs) in one week at 38 weeks of gestation is concerning. Rapid weight gain during pregnancy, particularly in the third trimester, can be a sign of fluid retention and may indicate potential complications such as preeclampsia, a serious hypertensive disorder of pregnancy, and warrants prompt evaluation by the provider. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
The nurse should determine that the FHR pattern represents Early decelerations due to Fetal head compression during contractions.
Rationale for correct answers:
Early decelerations are a gradual decrease and return to baseline of the fetal heart rate (FHR) associated with uterine contractions. They mirror contractions, beginning and ending with the contraction. This pattern is physiologic and typically benign.
Fetal head compression during contractions causes a vagal response leading to early decelerations. At a station of +4 and full dilation, fetal descent is significant, making head compression the most likely cause.
Rationale for incorrect Response 1 Options:
Late decelerations occur after the peak of the contraction and are due to uteroplacental insufficiency. These are non-reassuring and do not mirror contractions, unlike what is noted in the case.
Variable decelerations are abrupt drops in FHR and vary in timing, shape, and duration. They are not mirror images and are often associated with cord compression, which is not supported by this case’s findings.
Prolonged decelerations last >2 minutes and <10 minutes. The decelerations in this case are transient (to 105 bpm) and resolve before the end of the contractions, ruling out prolonged patterns.
Rationale for incorrect Response 2 Options:
Umbilical cord compression leads to variable decelerations, which are abrupt and not aligned with contraction timing, unlike the current pattern.
Uteroplacental insufficiency results in late decelerations, which occur after the contraction ends. These are non-reassuring and not consistent with the current findings.
Maternal hypotension due to epidural could cause late decelerations from reduced placental perfusion. However, despite a BP drop at 0900 (100/52 mm Hg), the FHR deceleration pattern does not match.
Take home points:
- Early decelerations are benign and typically reflect fetal head compression during contractions.
- Differentiate early from late decelerations based on timing relative to contractions—early mirrors, late lags.
- Variable decelerations are abrupt and typically linked to umbilical cord compression, not head compression.
- Maternal hypotension from epidural requires close monitoring, but it leads to uteroplacental insufficiency and late decelerations, not early.
Correct Answer is B
Explanation
Choice A rationale
While providing favorite foods can temporarily stimulate appetite, it does not address the underlying psychosocial issues contributing to nonorganic failure to thrive (NOFTT). NOFTT is often linked to impaired parent-child bonding and inadequate psychosocial stimulation, which manifest as poor feeding and developmental delays. A comprehensive approach is needed to resolve the root causes of the feeding difficulties.
Choice B rationale
Improving parental bonding and caloric intake is the most appropriate goal because nonorganic failure to thrive is primarily a result of inadequate nutritional intake often stemming from disturbed parent-child interactions. Enhanced bonding promotes a secure attachment, which is crucial for the child's emotional and physical development, leading to improved feeding behaviors and subsequent weight gain.
Choice C rationale
Increasing playtime with peers, while beneficial for social development, does not directly address the immediate and critical issues of malnutrition and impaired parent-child bonding in nonorganic failure to thrive. The primary concern in NOFTT is the child's physical health and the establishment of a nurturing environment to ensure adequate caloric intake and emotional security.
Choice D rationale
Encouraging the use of a pacifier for comfort might provide temporary solace but does not resolve the complex issues associated with nonorganic failure to thrive. The core problem is insufficient caloric intake and often, a lack of consistent, nurturing care. A pacifier may soothe, but it does not contribute to the essential nutritional and emotional repletion required for the child's growth and development.
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