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."

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Brewed green tea has 25-40 mg caffeine per 8 oz, from tea leaves’ natural stimulants. It exceeds cocoa, making it a higher-caffeine choice.

Choice B reason: Cola soft drinks contain 30-50 mg caffeine per 8 oz, added artificially. This surpasses cocoa’s level, placing it higher in caffeine content.

Choice C reason: Hot cocoa has 5-15 mg caffeine per 8 oz, naturally low from cocoa beans. It’s the least caffeinated option among these beverages.

Choice D reason: Instant coffee delivers 60-100 mg caffeine per 8 oz, concentrated from coffee grounds. It’s far higher than cocoa, unsuitable for reduction.

A. Diminished pulses on the affected extremity B. Ecchymosis on the inner left thigh C. Client report of muscle spasms of the left leg D. One fingerbreadth of space between the cast and the skin

Correct Answer is A

Explanation

Choice A reason: Diminished pulses signal compromised circulation, a critical cast complication like compartment syndrome. This risks tissue necrosis or amputation if untreated, prioritizing it scientifically, as arterial flow disruption demands immediate intervention to preserve limb viability per vascular assessment standards.

Choice B reason: Ecchymosis suggests bruising, possibly from cast pressure, but isn’t immediately life-threatening like poor circulation. It’s a secondary concern, manageable later. Scientifically, it indicates trauma, not acute vascular emergency, ranking lower in urgency per cast complication protocols.

Choice C reason: Muscle spasms may indicate irritation or pressure, but they’re less urgent than absent pulses. Pain is common in casts, not always critical. Scientifically, this suggests nerve or muscle stress, not imminent tissue loss, making it a lower priority for immediate action.

Choice D reason: One fingerbreadth space is normal, preventing tightness, not a concern. It’s ideal fit, not a problem. Scientifically, this aligns with safe cast application, lacking urgency compared to circulatory threats, as it supports, rather than jeopardizes, limb health.

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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?

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Naxlex Comprehensive Predictor Exams

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