A nurse is assessing a client who is at 30 weeks of gestation. Which of the following findings should the nurse identify as an indication of a potential prenatal complication?
Weight gain of 1.6 kg (3 lb 8 oz) in one month
Fundal height of 32 cm
Client report of leg cramps while sleeping
Presence of clonus
The Correct Answer is D
A. Weight gain of 1.6 kg (3 lb 8 oz) in one month: A weight gain of about 1–2 kg per month during the second and third trimesters is generally considered normal. This finding reflects appropriate maternal and fetal growth and does not indicate a complication.
B. Fundal height of 32 cm: At 30 weeks gestation, a fundal height between 28–32 cm is within normal limits, correlating approximately with gestational age in weeks. Minor variations can occur due to fetal position or maternal body habitus and are not automatically indicative of a complication.
C. Client report of leg cramps while sleeping: Leg cramps are a common musculoskeletal complaint during the third trimester, often due to changes in circulation, pressure from the uterus, and altered electrolyte balance. While uncomfortable, they are generally benign and not a sign of prenatal pathology.
D. Presence of clonus: Clonus—rapid, rhythmic involuntary contractions of the muscles, usually assessed at the ankle—is a neurological sign associated with hyperreflexia. In a pregnant client, the presence of clonus may indicate preeclampsia, a potentially serious prenatal complication involving hypertension and risk for seizures, requiring immediate evaluation and monitoring.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Ignore disruptive behaviors: Ignoring disruptive or inappropriate behaviors can contribute to a toxic work environment and increase emotional stress among staff. Addressing such behaviors through appropriate channels supports psychological safety and reduces the cumulative stress that contributes to compassion fatigue.
B. Publicly confront coworkers when conflict arises: Public confrontation can escalate conflict, damage professional relationships, and increase workplace stress. Effective conflict resolution requires respectful, private communication and the use of structured approaches, which helps maintain a supportive environment and reduces emotional exhaustion.
C. Encourage a passive communication style: Passive communication often leads to unexpressed concerns, unmet needs, and internalized stress, all of which contribute to burnout and compassion fatigue. Assertive communication is recommended instead, as it promotes clarity, mutual respect, and emotional well-being among healthcare staff.
D. Focus on self-care: Self-care is a cornerstone in preventing and managing compassion fatigue. Strategies such as adequate rest, stress management, emotional support, and maintaining work-life balance help nurses cope with repeated exposure to patient suffering. Prioritizing self-care enhances resilience, reduces burnout, and supports long-term professional functioning.
Correct Answer is D
Explanation
A. Back pain: Back pain is not a hallmark finding of postpartum endometritis. While some discomfort may occur due to uterine involution or positioning during labor, infection of the endometrial lining typically presents with uterine tenderness rather than isolated back pain. It is more commonly associated with musculoskeletal strain or renal conditions.
B. Bradycardia: Endometritis is an infectious process, and the body’s response typically includes tachycardia rather than bradycardia due to fever and systemic inflammation. Bradycardia would be inconsistent with the expected physiological response to infection and may suggest an alternative or unrelated condition.
C. Agitation: Although severe infection or sepsis can lead to altered mental status, agitation is not a primary or early sign of postpartum endometritis. More common early findings include fever, uterine tenderness, foul-smelling lochia, and systemic signs of infection rather than behavioral or cognitive disturbances.
D. Chills: Chills are a classic systemic manifestation of infection and are commonly associated with postpartum endometritis. The infection of the uterine lining triggers an inflammatory response, leading to fever and chills as the body attempts to fight the invading pathogens. These findings often occur alongside uterine tenderness and foul-smelling lochia.
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