At a prenatal visit at 36 weeks' gestation, a client complains of discomfort with irregularly occurring contractions (Braxton Hicks contractions). The nurse instructs the client to:
Walk around and increase fluid intake.
Time contractions for 30 minutes.
Take aspirin for the discomfort.
Go to the hospital.
The Correct Answer is A
Choice A rationale
Walking and increasing fluid intake can often alleviate the discomfort associated with Braxton Hicks contractions. Movement can sometimes cause the uterus to relax, and adequate hydration helps maintain uterine irritability within normal physiological limits. Dehydration can sometimes exacerbate uterine contractions, so ensuring sufficient fluid intake is a prudent measure.
Choice B rationale
Timing contractions is more relevant when assessing for true labor. Braxton Hicks contractions are irregular and do not follow a consistent pattern of increasing frequency, duration, and intensity. Instructing the client to time them for 30 minutes may cause unnecessary anxiety and is not the primary intervention for discomfort relief.
Choice C rationale
Aspirin is not recommended during pregnancy, especially in the third trimester, due to potential risks to both the mother and the fetus, such as increased bleeding tendencies. Furthermore, aspirin would not address the physiological cause of Braxton Hicks contractions.
Choice D rationale
Going to the hospital is not indicated for irregular, non-painful Braxton Hicks contractions, especially at 36 weeks' gestation. Hospital visits are reserved for signs of true labor, such as regular, increasing contractions, rupture of membranes, or significant bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Hyperemesis gravidarum is severe nausea and vomiting during pregnancy, typically occurring in the first trimester. Amniocentesis is a procedure performed later in pregnancy, so hyperemesis is not a direct complication of the procedure.
Choice B rationale
Proteinuria is the presence of protein in the urine, which can be a sign of preeclampsia during pregnancy. While amniocentesis carries a small risk of complications, proteinuria is not a direct expected complication of the procedure itself.
Choice C rationale
Hemorrhage, or excessive bleeding, is a potential complication of amniocentesis because the procedure involves inserting a needle through the abdominal wall and uterus to withdraw amniotic fluid. This can potentially damage blood vessels, leading to bleeding at the insertion site or internally.
Choice D rationale
Hypoxia is a condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level. While fetal well-being is monitored during and after amniocentesis, hypoxia is not a direct complication for the mother.
Correct Answer is B
Explanation
Choice A rationale
Caput succedaneum is swelling of the soft tissues of the newborn's scalp, often caused by pressure during vaginal delivery. It is a separate condition from cephalohematoma, which involves bleeding between the periosteum and the skull bone. Therefore, cephalohematoma does not increase the risk for caput succedaneum.
Choice B rationale
Jaundice, or hyperbilirubinemia, is a common condition in newborns due to the breakdown of fetal red blood cells and the immature liver's inability to efficiently process bilirubin. Cephalohematomas involve the rupture of blood vessels, leading to an increased breakdown of red blood cells. This releases more bilirubin into the bloodstream, thus elevating the risk of jaundice in infants with cephalohematomas. Normal total bilirubin levels in newborns range from 1 to 12 mg/dL, varying with age in days.
Choice C rationale
Infection is a risk associated with any break in the skin or invasive procedure, but a cephalohematoma itself is a collection of blood beneath the periosteum and does not inherently create an open wound or direct pathway for infection. While infection of a cephalohematoma is possible, it is not a primary increased risk associated with its development.
Choice D rationale
Erythema toxicum is a common, benign skin rash seen in newborns, characterized by small, yellow-white papules or pustules surrounded by red skin. Its etiology is unknown but it is thought to be an inflammatory reaction of the hair follicles. It is not related to the presence or development of a cephalohematoma.
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