A woman is in her seventh month of pregnancy.
She has been reporting nasal congestion and occasional epistaxis.
The nurse suspects that.
this is a normal respiratory change in pregnancy caused by elevated levels of estrogen.
this is an abnormal cardiovascular change, and the nosebleeds are an ominous sign.
the woman is a victim of domestic violence and is being hit in the face by her partner.
the woman has been using cocaine intranasally.
The Correct Answer is A
Choice A rationale:
Nasal congestion and occasional epistaxis (nosebleeds) are common symptoms during pregnancy due to elevated levels of estrogen. Increased estrogen causes mucosal blood vessels to become engorged and more fragile, leading to nasal congestion and occasional nosebleeds. This is a normal respiratory change in pregnancy and not necessarily a cause for concern.
Choice B rationale:
While cardiovascular changes are common in pregnancy, nosebleeds alone are not indicative of abnormal cardiovascular changes unless they are accompanied by other symptoms. The given scenario does not provide enough information to support this choice.
Choice C rationale:
There is no evidence provided to suggest domestic violence (Choice C) as the cause of the woman's symptoms. Additionally, this choice lacks a physiological basis for the symptoms described.
Choice D rationale:
Intranasal cocaine use (Choice D) can indeed cause nasal congestion and frequent nosebleeds. However, the scenario does not provide any information to support this choice, and assuming drug use without evidence is not appropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Magnesium sulfate is not given to improve patellar reflexes and increase respiratory efficiency (Choice A). It is primarily used to prevent and treat seizures (convulsions) in patients with preeclampsia and eclampsia.
Choice B rationale:
Magnesium sulfate does not shorten the duration of labor (Choice B). Its use is not related to the progression of labor but rather to prevent and control seizures in the context of preeclampsia and eclampsia.
Choice C rationale:
Preventing and treating convulsions (Choice C) is the main indication for administering magnesium sulfate in cases of severe preeclampsia and eclampsia. Magnesium sulfate acts as a central nervous system depressant, reducing the risk of seizures in these patients.
Choice D rationale:
Preventing a boggy uterus and lessening lochial flow (Choice D) are unrelated to the use of magnesium sulfate. These concerns are typically managed through uterine massage and other postpartum care measures, not magnesium sulfate administration.
Correct Answer is D
Explanation
Choice A rationale:
Leaving the infant in the room with the mother may not be appropriate, especially given the difficult delivery and the risk of complications, such as hypoglycemia.
Choice B rationale:
Taking the infant immediately to the nursery without monitoring vital signs and glucose levels could lead to missed signs of distress or hypoglycemia.
Choice C rationale:
Performing a gestational age assessment is important, but the immediate concern for this infant is the risk of hypoglycemia due to macrosomia (large birth weight). This choice does not address the immediate issue at hand.
Choice D rationale:
The correct answer. Macrosomic infants, especially those born after a difficult delivery, are at risk of hypoglycemia due to the excessive insulin production in response to high blood glucose levels. It is crucial to monitor the infant's blood glucose levels frequently and observe closely for signs of hypoglycemia, such as jitteriness, poor feeding, and lethargy.
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