A nurse is caring for a client who is at 36 weeks of gestation.
Which of the following findings should the nurse identify as the priority to assess further?

Increased leukorrhea.

Urinary frequency.

Persistent headache.

Insomnia.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Increased leukorrhea, or vaginal discharge, is a common and normal physiological finding during pregnancy due to increased estrogen levels and blood flow to the vaginal area. This increase in discharge helps prevent ascending infections. Unless accompanied by itching, odor, or color changes, it typically does not indicate a problem.

Choice B rationale

Urinary frequency is a common symptom in late pregnancy, particularly in the third trimester. It results from the enlarging uterus compressing the bladder, reducing its capacity, and increasing renal blood flow and glomerular filtration rate, leading to increased urine production. It is a normal physiological adaptation.

Choice C rationale

A persistent headache in a pregnant client, especially in the third trimester, is a priority to assess further because it can be a sign of preeclampsia, a serious hypertensive disorder of pregnancy. Other symptoms of preeclampsia include visual disturbances, right upper quadrant pain, and proteinuria. Early identification is crucial for intervention.

Choice D rationale

Insomnia is a common complaint during the third trimester of pregnancy. It can be attributed to various factors such as physical discomfort, frequent urination, fetal movements, anxiety, and hormonal changes. While bothersome, it is generally considered a normal, though often challenging, aspect of late pregnancy.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale

Avoiding sterile vaginal examinations is not a primary action for uterine atony and large vaginal bleeding. While excessive or repeated vaginal examinations can potentially introduce infection or dislodge clots, the immediate priority for uterine atony is to address the lack of uterine tone to prevent further blood loss.

Choice B rationale

Obtaining a specimen for a Kleihauer-Betke test is used to quantify the amount of fetal red blood cells in the maternal circulation, typically after a significant feto-maternal hemorrhage or trauma. While potentially useful in specific situations, it is not an immediate, primary intervention for acute uterine atony and bleeding.

Choice C rationale

Performing a fundal massage is the most immediate and critical action for uterine atony. Uterine atony is the leading cause of postpartum hemorrhage, characterized by a boggy, relaxed uterus that cannot effectively constrict blood vessels at the placental site. Manual massage stimulates uterine contractions, promoting vasoconstriction and reducing blood loss.

Choice D rationale

Assessing for abdominal tenderness is an important assessment, but it is not the primary intervention for acute uterine atony with large vaginal bleeding. Abdominal tenderness could indicate other complications such as uterine rupture or hematoma, which require different immediate interventions after addressing the atony.

A. "It can be helpful to talk about your loss with others who have experienced a pregnancy loss.”. B. "Once the fetus is passed, the provider will likely be able to determine what caused the pregnancy loss.”. C. "I have found that it is best to avoid seeing the fetal remains after the procedure.”. D. "It is okay to feel some grief now, even though it is so early in the pregnancy for a loss.”.

Correct Answer is ["A","D"]

Explanation

Choice A rationale

Providing an opportunity to connect with others who have experienced similar losses offers significant psychosocial support. Sharing experiences can normalize grief, reduce feelings of isolation, and validate emotions. This peer support can facilitate the grieving process by fostering a sense of community and understanding during a challenging time.

Choice B rationale

While some causes of spontaneous abortion can be identified, many remain unknown even after the expulsion of fetal tissue. Genetic anomalies, chromosomal abnormalities, or uterine factors are often implicated, but a definitive cause is not always determined. Providing this information can create unrealistic expectations and potential disappointment for the client.

Choice C rationale

The decision to view fetal remains is highly personal and depends on individual coping mechanisms and cultural beliefs. For some, it can be a crucial part of acknowledging the loss and beginning the grieving process. Advising against it prematurely removes a potential avenue for closure and validation for the client.

Choice D rationale

Validating the client's grief, regardless of the gestational age, is crucial for emotional well-being. Acknowledging that it is "okay to feel some grief now" provides permission for the client to experience their emotions. Grief is a subjective process, and the intensity and duration are not dictated by the length of the pregnancy.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client who is at 36 weeks of gestation. Which of the following findings should the nurse identify as the priority to assess further?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 1 hour postpartum and has uterine atony. The client is exhibiting a large amount of vaginal bleeding. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client at a 10-week prenatal visit. The provider diagnoses the client with a missed spontaneous abortion confirmed by ultrasound and the nurse is discussing the plan of care with the client. Which of the following statements should the nurse make?

Correct Answer is ["A","D"]

Explanation

A nurse is caring for a female client, age 30, at 37 weeks of gestation in the labor and delivery unit for blood pressure observation. After reviewing the client’s electronic health record, the nurse should identify that the client is at risk for developing which of the following complications?

A nurse is performing a nonstress test for a client who is at 38 weeks of gestation. The fetal monitor tracing reveals a series of late decelerations. Which of the following interventions should the nurse implement first?

A nurse is caring for a client in the emergency department who is in active labor on December 26. The client reports their last menstrual period was around April 1. Which of the following ages is the anticipated gestational age of the fetus?

A nurse is assessing the lifestyle practices of a pregnant client. Which of the following lifestyle factors indicates an increased risk for high-risk pregnancy?

A nurse is caring for a client who is at 36 weeks of gestation. Which of the following findings should the nurse identify as the priority to assess further?

A nurse is caring for a client who is at 36 weeks of gestation.
Which of the following findings should the nurse identify as the priority to assess further?