A nurse is providing education to a client on strict bedrest during the remainder of her pregnancy, who is currently 24 weeks.
Which of the following is a priority education topic for this client?
You may become more faint and lightheaded while laying down.
You should rise from sitting to standing slowly when getting out of bed.
Nasal stuffiness and nosebleeds are more common in pregnancy.
You can use saline sprays, nasal strips, and a humidifier while on bedrest.
The Correct Answer is D
Choice A rationale
Fainting and lightheadedness are common, but the education on rising slowly is not relevant for a client on strict bed rest who is not getting out of bed. The priority for this client is education on complications directly related to bed rest.
Choice B rationale
Nasal stuffiness and nosebleeds are common pregnancy symptoms due to increased blood volume and estrogen levels. However, this is not a priority education topic for a client on strict bed rest as it is not directly related to the complications of prolonged immobility.
Choice C rationale
Blood clots are a concern in pregnancy, and bed rest increases this risk. While wearing compression hose is correct, the education on moving around frequently is not possible for a client on strict bed rest and is therefore not a priority education topic.
Choice D rationale
Strict bed rest and the pressure of the gravid uterus can lead to urinary stasis, which significantly increases the risk for bladder infections. Therefore, it is a priority for the nurse to educate the client on emptying their bladder frequently to prevent this common and serious complication. *.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A reactive non-stress test (NST) is a reassuring finding that indicates adequate fetal oxygenation and an intact central nervous system. A reactive NST is defined by two or more fetal heart rate accelerations of at least 15 beats per minute above the baseline, lasting for at least 15 seconds, within a 20-minute period. Since this is a normal result, no further diagnostic testing is needed and monitoring can be discontinued.
Choice B rationale
An amniocentesis is an invasive diagnostic procedure used to assess for genetic abnormalities, fetal lung maturity, or infection. This procedure is generally not performed after a reactive NST, as the NST already provides reassuring information about fetal well-being, and amniocentesis carries risks such as infection, bleeding, or preterm labor.
Choice C rationale
An emergency cesarean delivery is indicated for severe fetal distress or other life-threatening complications. A reactive NST is a normal and reassuring finding, demonstrating a healthy fetus and adequate uterine environment, so an emergency cesarean delivery would be contraindicated and completely unnecessary.
Choice D rationale
A biophysical profile (BPP) is a more comprehensive assessment of fetal well-being that combines an NST with an ultrasound to evaluate fetal breathing, movement, tone, and amniotic fluid volume. A BPP is typically performed when the NST is non-reactive or equivocal. Given that the patient's NST was reactive, a BPP would not be the next anticipated step. *.
Correct Answer is ["B","C"]
Explanation
Choice A rationale
The statement is incorrect. While calcium and potassium are crucial electrolytes, their fluctuations are not the primary cause of dependent edema during pregnancy. The normal serum calcium level is 8.5-10.2 mg/dL, and the normal potassium level is 3.5-5.0 mEq/L. Swelling is predominantly a mechanical issue related to the growing uterus and hormonal changes, not electrolyte imbalances.
Choice B rationale
The statement is false. The swelling of the lower extremities, vulva, and rectum is not caused by changes in calcium and potassium levels. Instead, it is a multifactorial issue resulting from increased intravascular volume, venous pressure, and hormonal effects. This condition is also known as dependent edema and is a common physiological finding in pregnancy due to the weight of the uterus.
Choice C rationale
The statement is correct. As pregnancy progresses, the gravid uterus exerts increasing pressure on the inferior vena cava and pelvic veins, obstructing venous return from the lower extremities. Additionally, pregnancy-related increases in blood volume and capillary permeability contribute to fluid shifting from the intravascular space into the interstitial tissues, resulting in dependent edema.
Choice D rationale
The statement is incorrect. During a normal pregnancy, the body's blood volume actually increases by approximately 45% to meet the metabolic demands of the fetus and placenta. This increase in blood volume, coupled with hormonal changes (e.g., relaxin, estrogen), contributes to the increased fluid retention and subsequent swelling, not a decrease in blood volume
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