A nurse is collecting data from a client who is at 35 weeks of gestation. Which of the following findings should the nurse report to the provider?
Blurred vision
Leg cramps
Urinary frequency
Gingivitis
The Correct Answer is A
A. Blurred vision: Blurred vision during the third trimester can indicate a serious complication such as preeclampsia, which requires immediate reporting. It may signal elevated blood pressure and possible central nervous system involvement. Prompt communication with the provider is essential for maternal and fetal safety.
B. Leg cramps: Leg cramps are a common discomfort during pregnancy due to changes in circulation and pressure from the growing uterus. While uncomfortable, they are not considered an urgent finding that requires reporting.
C. Urinary frequency: Increased urinary frequency is typical in the third trimester as the enlarging uterus places pressure on the bladder. This is expected and usually does not indicate a complication unless accompanied by other symptoms such as pain or dysuria.
D. Gingivitis: Hormonal changes during pregnancy can lead to gum inflammation and bleeding. While oral care should be reinforced, gingivitis is a common, non-urgent finding and does not require immediate reporting to the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Bend forward with back parallel to the floor: The forward bend test, or Adam’s test, allows the nurse to observe for asymmetry of the ribs or spine, which are common indicators of scoliosis. This position accentuates spinal curvature for easier assessment.
B. Stand facing the nurse: Observing the client from the front does not provide a clear view of spinal curvature or asymmetry of the shoulders, ribs, or scapulae, which are key findings in scoliosis screening.
C. Lie supine with arms extended above head: This position is not effective for detecting spinal curvature or rib asymmetry, as scoliosis is best visualized with the client standing and bending forward.
D. Lie in a side-lying position: The side-lying (lateral) position is used for assessing pressure ulcers or administering enemas, but it does not provide the necessary alignment or visual access to detect the "S" or "C" curve of the spine characteristic of scoliosis.
Correct Answer is A
Explanation
A. Determine the client's pattern for voiding: Assessing the client’s typical voiding schedule provides essential baseline data to individualize the bladder training program. Understanding frequency, timing, and triggers allows the nurse to develop an effective and structured plan for toileting.
B. Discourage intake of carbonated beverages: Limiting bladder irritants can support continence but is secondary to first assessing the client’s voiding patterns. Dietary modifications alone will not optimize bladder training without an individualized schedule.
C. Offer toileting opportunities every 1 to 2 hr: Regular toileting supports bladder control, but it should be based on the client’s identified voiding pattern. Implementing a schedule before assessment may be inefficient or disruptive.
D. Assist the client with relaxation techniques: Relaxation can help facilitate voiding, but it is an adjunct intervention. Determining the voiding pattern first ensures that relaxation strategies are applied at appropriate times to maximize effectiveness.
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