A nurse is caring for a 26-year-old female client who is at 14 weeks of gestation in the antepartum clinic.
Select the 3 findings that are unexpected.
Weight loss
Breast tenderness
Heart rate
Vomiting
Nasal congestion
Respiratory rate
Correct Answer : A,C,D
Choice A rationale: Weight loss
Weight loss during pregnancy, especially in the second trimester, is unexpected unless there is a medical condition such as hyperemesis gravidarum or other nutritional deficiencies. While mild weight fluctuations can occur, a consistent loss of weight rather than gradual gain suggests inadequate caloric intake due to persistent vomiting and dehydration.
Choice B rationale: Breast tenderness
Breast tenderness is a common and expected physiological change during pregnancy due to hormonal fluctuations, particularly increased estrogen and progesterone levels. It is not considered abnormal or unexpected at this stage of pregnancy.
Choice C rationale: Heart rate
A heart rate of 116/min is unexpected, as it is above the normal range for adults (typically 60–100/min). Pregnancy can cause a mild increase in heart rate, but tachycardia above 110/min may indicate dehydration, anemia, or electrolyte imbalance, all of which can stem from excessive vomiting and fluid loss.
Choice D rationale: Vomiting
While occasional nausea and vomiting (morning sickness) can be expected in early pregnancy, persistent vomiting up to eight times daily and symptoms of dehydration (dry mucosa, poor skin turgor, positive ketones in urine) raise concern for hyperemesis gravidarum, a more severe form of pregnancy-related nausea and vomiting.
Choice E rationale: Nasal congestion
Nasal congestion is common during pregnancy due to increased blood volume and vascular changes affecting the nasal mucosa. It is not unexpected and does not indicate a complication.
Choice F rationale: Respiratory rate
A respiratory rate of 20/min falls within the normal range for adults (typically 12–20/min), making it an expected finding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A displaced fundus from the midline, often deviated to the right and boggy, suggests a full bladder interfering with uterine contraction and involution. A distended bladder prevents the uterus from clamping down effectively, increasing the risk of postpartum hemorrhage. Immediate intervention is required to assist the client in emptying her bladder, which should allow the uterus to return to the midline and contract firmly.
Choice B rationale
A fundal height below the umbilicus on the first postpartum day is a normal finding. Following delivery, the uterus begins to descend approximately one fingerbreadth (1 cm) per day. Therefore, a fundus below the umbilicus at 24 hours postpartum indicates normal uterine involution.
Choice C rationale
A decreased urge to void is common in the immediate postpartum period due to factors such as perineal swelling, pain, and the effects of anesthesia. While it's important to monitor urinary output, a decreased urge to void in the first 24 hours is not typically considered a finding requiring immediate intervention unless accompanied by other signs of urinary retention or bladder distension.
Choice D rationale
Increased urine output is also a normal finding in the postpartum period as the body eliminates excess fluid volume accumulated during pregnancy. Diuresis typically begins within 12 to 24 hours after delivery and can last for several days. This is a physiological process and does not require immediate intervention.
Correct Answer is A
Explanation
Choice A rationale
Mongolian spots are benign, flat bluish or bluish-gray birthmarks that commonly appear on the buttocks, lower back, or thighs of newborns, particularly those with darker skin tones, including African Americans, Asians, and Hispanics. They are caused by the entrapment of melanocytes (pigment-producing cells) deep within the dermis during fetal development. These spots typically fade spontaneously within a few years and are not indicative of any underlying medical condition or trauma.
Choice B rationale
Lanugo is fine, downy hair that covers the body of some newborns, especially preterm infants. It is usually shed within the last few weeks of gestation or shortly after birth and is unrelated to bruising or pigmented spots on the buttocks.
Choice C rationale
Nevus flammeus, also known as a port-wine stain, is a vascular malformation of the skin that appears as a flat, pink, red, or purple birthmark. It is caused by dilated capillaries and does not typically occur as bluish spots on the buttocks. Port-wine stains are usually permanent and may darken with age.
Choice D rationale
Vascular nevus, also known as a strawberry hemangioma, is a raised, red, bumpy birthmark composed of extra blood vessels. While it is a type of birthmark, it does not present as flat, bluish spots on the buttocks. Hemangiomas typically grow rapidly in the first few months of life and then gradually shrink over several years.
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