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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Professor Proctor emphasizes safety as the highest priority while traveling, including when coming to class. Ensuring that students arrive safely is considered more important than strict punctuality.
Correct Answer is C
Explanation
A. Jaundice. Oxytocin does not cause jaundice in the mother. Jaundice is typically related to liver dysfunction, hemolysis, or bile obstruction and is not an expected side effect of oxytocin administration.
B. Dehydration. While prolonged labor induction may contribute to dehydration if fluid intake is insufficient, oxytocin itself does not directly cause dehydration. IV fluids are typically administered alongside oxytocin to maintain hydration during labor.
C. Uterine hyperstimulation. Uterine hyperstimulation (tachysystole), defined as more than five contractions in 10 minutes, is a serious complication of oxytocin administration. It can lead to fetal distress, uterine rupture, and impaired placental perfusion. If hyperstimulation occurs, the nurse should discontinue oxytocin, reposition the patient, provide oxygen, and notify the provider.
D. Maternal bradycardia. Oxytocin does not typically cause bradycardia. Maternal side effects are more commonly tachycardia, hypertension, or fluid retention. Fetal bradycardia, however, can occur if uterine hyperstimulation leads to fetal hypoxia.
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.