A nurse is caring for a client who is at 34 weeks of gestation. Which of the following statements by the client is the nurse’s priority to report to the provider?
"My heart feels like it skips a beat."
"I have nosebleeds once per week."
"The palms of my hands are red and blotchy."
"I’m experiencing persistent headaches."
The Correct Answer is A
Choice A reason: Palpitations at 34 weeks may signal arrhythmia or preeclampsia-related cardiac strain. This urgent symptom in pregnancy requires immediate provider evaluation.
Choice B reason: Weekly nosebleeds are common in pregnancy from vascular changes, less critical. Without severity, they’re not the priority over cardiac concerns.
Choice C reason: Red, blotchy palms (palmar erythema) are normal in pregnancy from estrogen. It’s benign, not urgent compared to potential heart issues.
Choice D reason: Persistent headaches suggest preeclampsia, but palpitations pose a more immediate cardiac risk. At 34 weeks, this takes reporting precedence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Injecting 15 units of air into regular insulin balances vial pressure, per protocol. This step precedes drawing regular insulin, ensuring accurate mixing sequence.
Choice B reason: Withdrawing NPH now skips regular insulin prep, risking contamination or error. Air injection into both vials comes first in standard insulin administration.
Choice C reason: Verification is key but follows insulin preparation. Air injection sequence precedes dosage checks, making this premature before completing vial prep steps.
Choice D reason: Capping the needle halts the process prematurely. Air must be injected into both vials first to maintain sterile technique and accurate dosing.
Correct Answer is D
Explanation
Choice A reason: Sims’ position is for rectal exams, not central catheter insertion. Trendelenburg or supine is used, so this is incorrect for TPN prep.
Choice B reason: Verifying TPN amount is ongoing care, not insertion prep. Initial placement confirmation via x-ray takes precedence over infusion monitoring here.
Choice C reason: Clean technique risks infection in central lines; sterile is required. This compromises TPN safety, making it an incorrect preparatory step.
Choice D reason: Chest x-ray confirms catheter tip placement in the vena cava for TPN. It’s a critical prep step to ensure safe administration begins.
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