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 B
Explanation
Choice A rationale
Telling the adolescent that wearing the brace is mandatory and refusal is noncompliant behavior can lead to defiance and resentment. This approach fails to acknowledge the adolescent's autonomy and emotional well-being, potentially decreasing adherence due to a feeling of being controlled rather than empowered in their own care.
Choice B rationale
Encouraging expression of feelings provides a safe space for the adolescent to process the emotional challenges associated with brace wear. Connecting with a peer support group offers validation and coping strategies from individuals facing similar experiences, promoting a sense of community and reducing feelings of isolation, thereby improving adherence.
Choice C rationale
Advising the mother to monitor brace usage closely and report nonadherence shifts the responsibility to the parent, potentially fostering conflict and reducing the adolescent's sense of ownership over their treatment. This approach can also lead to increased family tension and further resistance from the adolescent.
Choice D rationale
Emphasizing the importance of brace wear for spinal correction and future mobility is crucial for understanding the therapeutic benefits. However, this cognitive understanding alone may not be sufficient to address the psychosocial and emotional challenges adolescents face, which significantly influence adherence to a restrictive treatment like bracing.
Correct Answer is D
Explanation
Choice A rationale
Immediately initiating urological testing without first assessing for psychological factors is premature. While organic causes of enuresis exist, a sudden onset in a 12-year-old following a significant stressor like parental divorce strongly suggests a psychological etiology. Unnecessary invasive testing can be distressing for the child.
Choice B rationale
Punishing a child for bedwetting is detrimental and ineffective. Enuresis, especially stress-induced, is an involuntary act; punishment increases anxiety and shame, exacerbating the problem rather than resolving it. This approach can damage the child's self-esteem and the parent-child relationship.
Choice C rationale
Informing the child they are too old for bedwetting shames them and ignores the underlying emotional distress. This approach fosters guilt and inadequacy, reinforcing negative self-perceptions rather than addressing the root cause. Empathy and support are crucial for managing stress-related symptoms.
Choice D rationale
Providing emotional support and assessing for enuresis as a stress response is the most appropriate initial intervention. The sudden onset of bedwetting after parental divorce strongly suggests a psychological component. Addressing the emotional impact and providing coping strategies can alleviate the stress, leading to resolution of the enuresis.
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