A nurse conducts a physical exam of a client who reports feeling well.
Findings include:
General: No acute distress.
Cardiovascular: No murmur or rub.
Respiratory: Bilateral breath sounds clear.
Abdomen: Fundal height 38 cm.
Genitourinary: Purulent cervical discharge.
The Correct Answer is E
Choice A rationale
No acute distress indicates the client's physiological stability. It reflects an absence of acute systemic responses like tachycardia or labored breathing, suggesting normal homeostasis during examination.
Choice B rationale
No cardiovascular murmurs or rubs imply normal valve function and an absence of pericardial inflammation. This finding indicates no pathological blood flow changes or cardiac friction sounds.
Choice C rationale
Clear bilateral breath sounds suggest open airways and proper ventilation, excluding lower respiratory tract issues like pneumonia. Normal respiratory examination confirms adequate pulmonary function.
Choice D rationale
Fundal height at 38 cm corresponds to late-third trimester pregnancy. It reflects uterine enlargement due to fetal growth, indicating gestational progression but unrelated to cervical discharge.
Choice E rationale
Purulent cervical discharge suggests an ongoing infection, likely bacterial cervicitis. It reflects leukocyte accumulation due to pathogenic invasion, requiring clinical intervention to prevent complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Nevus flammeus is a capillary malformation, presenting as a flat, purple-red birthmark that does not cause swelling or cross suture lines, distinguishing it from caput succedaneum.
Choice B rationale
Caput succedaneum involves swelling of the scalp caused by pressure during delivery, often crossing suture lines due to subcutaneous fluid accumulation, a hallmark distinguishing it from other neonatal head conditions.
Choice C rationale
Cephalohematoma is a subperiosteal hemorrhage limited by suture lines, making it distinct from caput succedaneum, which crosses suture lines and involves diffuse subcutaneous swelling.
Choice D rationale
Erythema toxicum is a benign, blotchy skin condition in neonates that does not affect the scalp or cause swelling, further distinguishing it from conditions related to traumatic delivery.
Correct Answer is B
Explanation
Choice A rationale
Vitamin E is crucial for cell protection but is not required in increased amounts during pregnancy. Its supplementation is not routinely recommended unless a deficiency is present.
Choice B rationale
Protein requirements increase to support fetal growth, placental development, and maternal tissue expansion. Pregnant clients need approximately 1.1 g/kg/day, compared to 0.8 g/kg/day for non-pregnant individuals.
Choice C rationale
While fiber is important for digestive health, its intake does not specifically increase during pregnancy. Adequate fiber prevents constipation, but no additional intake is routinely advised.
Choice D rationale
Calcium supports fetal bone development, but its recommended intake of 1,000 mg/day remains unchanged. Prenatal needs do not require exceeding normal adult calcium recommendations. .
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