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 D
Explanation
Choice A rationale:
Abdominal respirations do not directly predispose toddlers to frequent infections such as otitis media, tonsillitis, and upper respiratory tract infections. Abdominal respirations are a normal breathing pattern in toddlers, transitioning from the diaphragmatic breathing seen in infants. This change is due to the toddler's increased chest wall compliance and stronger intercostal muscles, facilitating more efficient breathing.
Choice B rationale:
Slower pulse and respiratory rates in toddlers compared to infants are part of normal physiological development. Toddler's heart rates range from 70 to 110 beats per minute, and respiratory rates range from 20 to 30 breaths per minute. These rates are considered normal for toddlers and do not predispose them to frequent infections.
Choice C rationale:
Toddlers do have less efficient defense mechanisms than infants, making them more susceptible to infections. This is due to the immature immune system in toddlers, which is still developing and learning to respond to various pathogens. However, this choice is not the most important factor predisposing toddlers to frequent infections; other factors play a more significant role.
Choice D rationale:
The presence of short, straight internal ear/throat structures and large tonsil/adenoid lymph tissue in toddlers is the most important factor predisposing them to frequent infections such as otitis media, tonsillitis, and upper respiratory tract infections. These anatomical features make it easier for bacteria and viruses to enter and infect the respiratory and ear passages, leading to recurrent infections.
Correct Answer is B
Explanation
Choice A rationale:
A respiratory rate of 10 bpm (breaths per minute) is significantly below the normal range for an adult but is within the normal range for a newborn. Since the question does not specify the client's age, this information is insufficient to identify it as a complication of magnesium sulfate administration.
Choice B rationale:
A blood pressure of 148/94 is elevated and could be a complication of magnesium sulfate administration. Magnesium sulfate is used to manage pregnancy-induced hypertension, so if the blood pressure remains high or increases further, it could indicate an inadequate response to the treatment or a potential complication.
Choice C rationale:
Deep tendon reflexes of +2 are within the normal range and are not indicative of a complication related to magnesium sulfate administration. In fact, magnesium sulfate can cause muscle weakness and decreased deep tendon reflexes, so an absence of reflexes or extremely diminished reflexes might be a cause for concern.
Choice D rationale:
A urine output of 70 ml/hour is within the normal range for an adult, but without additional information, it is not indicative of a complication related to magnesium sulfate administration. Monitoring urine output is essential to assess renal function and fluid balance, but in this context, it does not provide specific information about the effects of magnesium sulfate.
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