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 D
Explanation
Choice A rationale
An alpha-fetoprotein (AFP) test is a blood test that measures the levels of AFP in the maternal serum. This test does not require any specific dietary restrictions, such as fasting. Therefore, advising the client to abstain from food or drink for 8 hours before the test is not based on physiological necessity for accurate AFP measurement.
Choice B rationale
Test results are influenced by various factors, including gestational age, multiple pregnancies, and certain fetal anomalies. While chronic illnesses can impact overall health, they do not directly determine the outcome of an AFP screening test, which primarily assesses the risk of neural tube defects or chromosomal abnormalities.
Choice C rationale
An AFP test is a simple blood draw and is not an invasive procedure. Therefore, there is no physiological need for bed rest following the test. Clients can resume their normal activities immediately after the blood sample is collected, as there are no associated post-procedure complications requiring immobility.
Choice D rationale
The AFP test is a screening tool, meaning it identifies individuals who may be at an increased risk for certain conditions, such as neural tube defects or Down syndrome. It does not provide a definitive diagnosis. Abnormal screening results necessitate further diagnostic testing, such as amniocentesis or high-resolution ultrasound, for confirmation.
Correct Answer is A
Explanation
Choice A rationale
Providing a calm, structured environment with consistent routines helps children with ADHD regulate their behavior and attention. Predictable schedules and clear expectations reduce sensory overload and provide a framework for self-management, thereby promoting focus and minimizing disruptive behaviors by optimizing neurological processing.
Choice B rationale
Removing the child from the classroom as a primary intervention is counterproductive. While a brief cool-down period might sometimes be useful, consistent removal can isolate the child, disrupt their learning, and prevent them from developing coping mechanisms within the regular classroom setting, hindering social and academic integration.
Choice C rationale
Punishing a child with ADHD each time rules are broken is generally ineffective and can be detrimental. ADHD is a neurodevelopmental disorder affecting impulse control and attention; punishment alone does not address the underlying neurological differences. It can lead to increased anxiety, defiance, and a negative self-concept.
Choice D rationale
Recommending home schooling for a child with ADHD should not be the most appropriate first intervention. While home schooling can be an option for some families, it removes the child from valuable social learning experiences and peer interaction crucial for development. Classroom interventions and support should be exhausted first.
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