A nurse is caring for a client who is at 22 weeks of gestation and reports concern about the blotchy hyperpigmentation on her forehead. Which of the following actions should the nurse take?
Tell the client to follow up with a dermatologist
Explain to the client this is an expected occurrence.
instruct the client to increase her intake of vitamin D
Inform the client she might have an allergy to her skin care products
The Correct Answer is B
The correct answer is B. Explain to the client this is an expected occurrence.
A. Tell the client to follow up with a dermatologist: While it's always good to encourage clients to seek professional advice if they have concerns, in the context of melasma during pregnancy, it is generally a normal physiological change. A dermatologist may not be needed specifically for this condition unless there are other unusual symptoms.
B. Explain to the client this is an expected occurrence: This is the correct action. It's important for the nurse to reassure the client that blotchy hyperpigmentation on the forehead is a common and expected change during pregnancy. Providing education and support can help alleviate the client's concerns.
C. Instruct the client to increase her intake of vitamin D: Blotchy hyperpigmentation is not typically addressed by increasing vitamin D intake. While adequate nutrition is important during pregnancy, this specific concern is related more to hormonal changes than nutritional deficiencies.
D. Inform the client she might have an allergy to her skin care products: Melasma is primarily related to hormonal changes in pregnancy rather than an allergic reaction to skin care products. While assessing for allergies is essential in certain situations, it may not be the primary concern in this case.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is C. Observe for crowning.
A. Applying fundal pressure is not indicated when the fetal head is at 3+ station. Fundal pressure is generally discouraged as it can increase the risk of fetal and maternal complications.
B. Preparing to administer oxytocin may be necessary later in labor but is not the immediate priority when the fetal head is still at 3+ station.
C. Observing for crowning is the correct action.
Crowning occurs when the widest part of the fetal head is visible at the vaginal opening during contractions. It is a sign that the baby is descending and the client is in the second stage of labor.
D. Observing for the presence of a nuchal cord is a valid consideration, but observing for crowning takes precedence at this stage of labor. Nuchal cords can be managed appropriately once the fetal head has descended further.
Correct Answer is D
Explanation
A. Contractions lasting longer than 90 seconds: Prolonged contractions lasting longer than 90 seconds may indicate uterine hyperstimulation, which can compromise fetal oxygenation and lead to fetal distress. This finding should be reported to the provider promptly for further evaluation and management.
B. Client reports feeling contractions in the lower back: This is a common sensation during labor and may not necessarily indicate a complication. However, if associated with other signs of fetal distress, it should be reported.
C. Contractions occurring every 3 to 5 minutes: This frequency is within the normal range for the active phase of labor and does not necessarily indicate a problem. However, it is essential to consider the duration and intensity of contractions along with this frequency.
D. Contractions are strong in intensity: While strong contractions are typical during the active phase of labor, the intensity alone may not be a cause for concern unless they are associated with uterine hyperstimulation.
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