A nurse is assessing a client who is at 31 weeks of gestation. Which of the following findings should the nurse identify as an indication of a potential prenatal complication?

Periodic tingling of fingers.

Absence of clonus.

Leg cramps.

Blurred vision.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Periodic tingling of fingers is a common symptom during pregnancy and is often related to hormonal changes and increased fluid retention. While it can be uncomfortable, it is not necessarily an indication of a potential prenatal complication.

Choice B rationale:

Absence of clonus is not an abnormal finding during pregnancy. Clonus is a series of involuntary muscle contractions and relaxations and is generally not expected during a routine assessment.

Choice C rationale:

Leg cramps are a common complaint during pregnancy and are usually caused by changes in calcium and magnesium levels. While they can be uncomfortable, they are not typically considered an indication of a potential prenatal complication.

Choice D rationale:

Blurred vision can be an indication of preeclampsia, a serious condition that can occur during pregnancy. Preeclampsia is characterized by high blood pressure and damage to organs, often affecting the eyes, kidneys, and liver. It is crucial for the nurse to recognize this symptom and promptly inform the healthcare provider for further evaluation and management.

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Correct Answer is D

Explanation

Choice D rationale:

During the transition phase of labor, the nurse should encourage the client to use a pant- blow breathing pattern. The transition phase is intense, and pant-blow breathing (a form of controlled breathing) can help the client manage the pain and reduce anxiety. Panting during contractions allows the client to focus on short, shallow breaths, which can be more effective than deep breathing during this stage.

Choice A rationale:

Assisting the client to void every 3 hours is important during labor, but it is not specific to the transition phase. The nurse should encourage the client to void regularly during the entire labor process to prevent bladder distension and facilitate the descent of the baby. However, during the transition phase, the client may be more focused on contractions and may not need reminders to void every 3 hours.

Choice B rationale:

Monitoring contractions every 30 minutes is not appropriate during the transition phase of labor. The transition phase is characterized by frequent and strong contractions, and continuous monitoring of contractions is usually required during this phase to ensure fetal well-being and progress in labor.

Choice C rationale:

Placing the client into a lithotomy position is not appropriate during the transition phase of labor. The lithotomy position, where the client lies on their back with legs raised and supported in stirrups, is often used during the pushing phase. During the transition phase, it is more common for the client to be in an upright or semi-reclining position to facilitate the descent of the baby through the birth canal.

A. Assist the family to identify prior use of positive coping skills in family crises. B. Ask the client if she has considered harming her newborn. C. Anticipate a prescription by the provider for an antidepressant. D. Reinforce postpartum and newborn care discharge teaching.

Correct Answer is B

Explanation

Choice A rationale:

Assisting the family in identifying prior coping skills is a valuable nursing intervention, but it is not the priority action in this situation. The client's feelings of sadness and lack of energy raise concerns about postpartum depression, and the nurse should address potential harm to the newborn first.

Choice B rationale:

This is the priority action by the nurse. The client's symptoms are indicative of postpartum depression, and the nurse must assess if she has considered harming her newborn. This assessment is crucial for the safety and well-being of both the mother and the baby.

Choice C rationale:

Anticipating a prescription for an antidepressant may be appropriate once a proper assessment and diagnosis are made, but it is not the priority action at this stage. Assessing for potential harm to the newborn takes precedence.

Choice D rationale:

Reinforcing postpartum and newborn care discharge teaching is essential for the client's well- being. However, it is not the priority action when the client is showing signs of postpartum depression and possible harm to the newborn.

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A nurse is assessing a client who is at 31 weeks of gestation. Which of the following findings should the nurse identify as an indication of a potential prenatal complication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in the transition phase of labor. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling "down” and sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse?

Correct Answer is B

Explanation

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