A woman with a history of congestive heart disease is 36 weeks pregnant. Which of the following findings should the nurse report to the primary health care practitioner?

Weight gain of 4 pounds in a month.

Dyspnea with walking.

Presence of striae gravidarum.

Patellar reflexes of +2.

Answer and Explanation

The Correct Answer is B

A. Weight gain of 4 pounds in a month. A weight gain of 4 pounds in a month is within the expected range for pregnancy, especially in the third trimester. While rapid or excessive weight gain could indicate fluid retention and worsening heart failure, this amount alone is not immediately concerning.

B. Dyspnea with walking. Dyspnea on exertion in a pregnant woman with congestive heart disease is a serious concern. It may indicate pulmonary congestion, worsening heart failure, or reduced cardiac output. Any increasing shortness of breath, especially with minimal activity, should be reported immediately to prevent complications like pulmonary edema or decompensated heart failure.

C. Presence of striae gravidarum. Striae gravidarum (stretch marks) are a normal skin change in pregnancy due to rapid growth and stretching of the skin. They are not related to congestive heart disease and do not require reporting.

D. Patellar reflexes of +2. A +2 deep tendon reflex (DTR) is normal and does not indicate worsening cardiac status. Reflex abnormalities are more relevant in conditions such as preeclampsia, where hyperreflexia can signal worsening disease, but they are not a concern in heart disease.

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Correct Answer is A

Explanation

A. Stay with the patient and call for help. The priority during a seizure is to ensure the patient’s safety and call for immediate assistance. The nurse should stay with the patient, protect her from injury, and note the seizure’s duration and characteristics. After the seizure ends, further interventions can be implemented.

B. Suction the mouth to prevent aspiration. Suctioning should only be performed after the seizure ends. Attempting to suction during an active seizure increases the risk of injury and airway obstruction.

C. Insert an oral airway. Inserting an oral airway during an active seizure is unsafe and contraindicated because it may cause trauma to the mouth or airway. An airway can be inserted after the seizure stops if necessary.

D. Administer oxygen by tight face mask. While oxygen is important, it should be provided after the seizure subsides and the airway is assessed. The primary focus during the seizure is safety, preventing injury, and calling for emergency assistance.

A. "My baby dropped, and I have to urinate more frequently now." B. The contractions in my uterus are getting stronger and closer together" C. I passed some thick pink mucus where I urinated this morning" D. "My bag of waters just broke’

Correct Answer is B

Explanation

A. Increased urinary frequency and the baby "dropping" indicate lightening, which occurs in the weeks before labor begins. While this is a sign that labor is approaching, it does not confirm true labor.
B. True labor is characterized by contractions that progressively become stronger, closer together, and more regular, leading to cervical dilation and effacement. This distinguishes it from false labor, where contractions are irregular and do not cause cervical changes.
C. Passing thick pink mucus, known as the bloody show, is a sign that labor may begin soon, but it does not confirm that the woman is in active labor. Cervical changes must be assessed to determine true labor.
D. The rupture of membranes, or "water breaking," can occur before or during labor, but it does not necessarily indicate the onset of true labor. Cervical dilation and regular contractions are required to confirm active labor.

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A woman with a history of congestive heart disease is 36 weeks pregnant. Which of the following findings should the nurse report to the primary health care practitioner?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A woman with preeclampsia has a seizure. The nurse's primary duty during the seizure is to:

Correct Answer is A

Explanation

The nurse recognizes that a woman is in true labor when she states…., and finds that her cervix has dilated and effaced on examination.

Correct Answer is B

Explanation

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