A nurse is collecting data from a client who is at 36 weeks of gestation.
Which of the following findings requires immediate follow-up?
Urinary frequency.
Edema in lower extremities.
Decreased fetal movement.
Periodic contractions.
The Correct Answer is C
Choice A rationale
Urinary frequency is a common and expected finding at 36 weeks of gestation. As the fetus grows and moves lower into the pelvis, the uterus exerts significant pressure on the bladder, reducing its capacity. While the nurse should monitor for signs of infection, such as dysuria or cloudy urine, frequency alone is a physiological consequence of late-term pregnancy and does not indicate an immediate emergency or the need for urgent clinical intervention.
Choice B rationale
Edema in the lower extremities, particularly the feet and ankles, is a frequent occurrence in the third trimester. It results from increased venous pressure in the lower body and the systemic increase in fluid volume. While the nurse should assess for signs of preeclampsia, such as facial swelling or hypertension (blood pressure ≥ 140/90 mmHg), mild dependent edema is generally considered a normal discomfort of pregnancy rather than a finding requiring immediate, emergency follow-up.
Choice C rationale
Decreased fetal movement is a critical finding that requires immediate follow-up as it can indicate fetal distress or hypoxia. Fetal kick counts are used to monitor well-being; a significant reduction in activity may signal that the fetus is not receiving adequate oxygen or nutrients through the placenta. Immediate evaluation via a non-stress test or biophysical profile is necessary to assess the fetal heart rate and ensure there is no immediate threat to fetal life.
Choice D rationale
Periodic contractions, often referred to as Braxton Hicks contractions, are common at 36 weeks as the body prepares for labor. These are typically irregular and do not increase in intensity or frequency. While they can be uncomfortable, they are a normal part of late pregnancy. The nurse should provide education on distinguishing these from true labor, but their presence alone is not an alarming finding requiring immediate intervention unless accompanied by cervical changes or rupture of membranes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
This response provides clear, evidence-based guidance without being judgmental. There is no known safe amount of alcohol consumption during pregnancy, and any intake can lead to Fetal Alcohol Spectrum Disorders. By stating that no alcohol is recommended for the best outcomes, the nurse establishes a firm clinical boundary while focusing on the health of the fetus. This approach empowers the client with factual information to make an informed decision regarding her prenatal health.
Choice B rationale
This statement is scientifically inaccurate and uses fear-based tactics, which is non-therapeutic. While alcohol is a known teratogen that can cause significant structural and functional brain damage, growth restriction, and facial dysmorphology, it does not typically cause the fetal heart to stop beating immediately after one glass of wine. Providing false information undermines the nurse's credibility and may cause unnecessary extreme anxiety for the client if she has already consumed alcohol.
Choice C rationale
This response is dangerously incorrect. While the first trimester is a critical period for organogenesis, alcohol consumption in the second and third trimesters also poses severe risks. Alcohol exposure later in pregnancy can interfere with complex brain development, leading to cognitive impairments, behavioral issues, and learning disabilities. Suggesting that the baby will be okay if alcohol is consumed after the first trimester neglects the lifelong risks associated with Fetal Alcohol Spectrum Disorders.
Choice D rationale
This response is highly non-therapeutic because it uses a "why" question, which often sounds accusatory and judgmental. It shames the client for her feelings of being overwhelmed and for her inquiry, which can shut down the therapeutic relationship. Instead of exploring the client's stress and providing support or coping mechanisms, this response creates a defensive atmosphere and discourages the client from being honest with the healthcare team in the future.
Correct Answer is C
Explanation
Choice A rationale
Hyperventilation in pregnancy is often a compensatory mechanism due to increased progesterone levels stimulating the respiratory center, but it does not explain the sudden relief in breathing described by the client. Hyperventilation usually causes a decrease in arterial carbon dioxide levels and can lead to dizziness or tingling. The client's description specifically points to a mechanical change in the physical capacity of the lungs rather than a change in respiratory rate.
Choice B rationale
Decreased carbon dioxide production does not occur at the end of pregnancy; in fact, maternal basal metabolic rate and oxygen consumption increase significantly to support the fetus and placenta. The feeling of being able to breathe better is not related to chemical changes in gas production but rather to the physical relocation of the fetus. The total metabolic demand on the maternal system remains high until delivery, maintaining a steady need for gas exchange.
Choice C rationale
Lightening occurs when the fetal presenting part descends into the true pelvis, which typically happens a few weeks before labor in primigravidas. This descent reduces the upward pressure of the uterus on the diaphragm, allowing for greater lung expansion and easier breathing. While this provides respiratory relief, it often increases pressure on the urinary bladder, leading to increased urinary frequency and changes in the maternal gait due to the shifting center of gravity.
Choice D rationale
Decreasing chest diameter would actually impair the client's ability to breathe rather than improve it. During pregnancy, the chest diameter typically increases as the rib cage flares outward to accommodate the growing uterus and the displaced diaphragm. A decrease in chest diameter is not a physiological occurrence at thirty-nine weeks of gestation. The sensation of improved breathing is strictly due to the fetus moving lower, not the rib cage becoming smaller.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.