Identify which of the following findings is a priority concern or not for the patient.

Headache is a priority concern.

Gestational age is not a priority concern.

Heartburn is not a priority concern.

Abnormal liver function tests are a priority concern.

Answer and Explanation

Correct Answer : A,D

Choice A rationale

Headache in a postpartum patient, especially if severe, persistent, or accompanied by visual disturbances or hypertension, can be a sign of serious conditions such as preeclampsia or postpartum eclampsia. These conditions require immediate medical attention due to the potential for significant maternal morbidity and mortality.

Choice B rationale

Gestational age is a historical data point related to the pregnancy and delivery. While important for understanding the newborn's potential risks and maturity, it is not a priority concern in the immediate postpartum period for the mother unless complications related to preterm or post-term delivery arise in the mother.

Choice C rationale

Heartburn, or pyrosis, is a common discomfort during pregnancy due to hormonal changes and pressure on the stomach. While it can persist postpartum, it is generally not a priority concern unless it is severe, atypical, or associated with other concerning symptoms like chest pain, which could indicate a different underlying issue.

Choice D rationale

Abnormal liver function tests in the postpartum period can indicate serious conditions such as HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count), a severe form of preeclampsia that can occur postpartum. These abnormalities require prompt investigation and management due to the potential for life-threatening complications. .

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Correct Answer is A

Explanation

Choice A rationale

Applying warm compresses before breastfeeding promotes vasodilation, increasing blood flow to the breast tissue. This facilitates milk let-down by relaxing the smooth muscles around the alveoli and ducts, making it easier for the infant to latch and nurse effectively, thereby relieving engorgement and associated pain.

Choice B rationale

Limiting fluid intake is contraindicated for breast engorgement. Adequate hydration is essential for maintaining milk production. Reducing fluids can lead to dehydration and potentially decrease milk supply, exacerbating engorgement and discomfort rather than alleviating it.

Choice C rationale

Applying cold compresses after breastfeeding helps to reduce inflammation and swelling in the breast tissue. The cold temperature causes vasoconstriction, which decreases blood flow and can minimize discomfort and engorgement by reducing tissue edema.

Choice D rationale

Frequent breastfeeding or regular pumping helps to remove milk from the breasts, which is the primary intervention for relieving engorgement. Regular emptying prevents milk from accumulating in the ducts and alveoli, reducing pressure and pain. This also helps establish and maintain milk supply.

Choice E rationale

Wearing a tight-fitting bra can restrict milk flow and increase pressure on the breast tissue, potentially worsening engorgement and causing discomfort. A supportive but not restrictive bra is recommended to provide comfort without impeding circulation or milk ducts.

A. "The fetal heart pumps blood to both the placenta and the developing organs.”. B. "Maternal and fetal blood mix to allow for nutrient and oxygen exchange.”. C. "The placenta is the site of gas exchange for the fetus.”. D. "The umbilical arteries carry deoxygenated blood from the fetus to the placenta.”.

Correct Answer is B

Explanation

Choice A rationale

The fetal heart indeed pumps blood to both the placenta, where oxygen and nutrients are obtained, and to the developing organs, which require these substances for growth and function. This dual circulation is essential for fetal development. The normal circulatory pattern ensures that oxygenated blood returns from the placenta to nourish the fetal tissues, while deoxygenated blood is transported back to the placenta for gas exchange.

Choice B rationale

Maternal and fetal blood do not mix under normal physiological conditions. The exchange of gases, nutrients, and waste products occurs across the placental barrier, which consists of fetal and maternal tissues but keeps their bloodstreams separate. This separation prevents potential immune reactions and maintains distinct circulatory systems for the mother and the fetus.

Choice C rationale

The placenta serves as the vital site for gas exchange in the fetus. Oxygen and carbon dioxide are exchanged between the maternal and fetal blood across the placental membranes via diffusion. Oxygen-rich blood from the mother is delivered to the fetus, while carbon dioxide, a waste product of fetal metabolism, moves from the fetus to the mother for elimination.

Choice D rationale

The umbilical arteries are responsible for carrying deoxygenated blood and waste products from the fetus to the placenta. This deoxygenated blood is then oxygenated and cleared of waste at the placenta before returning to the fetus via the umbilical vein. This flow pattern is crucial for maintaining the fetal environment and supporting its development.

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Identify which of the following findings is a priority concern or not for the patient.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with the nursing diagnosis of acute pain related to breast engorgement.Which interventions should the nurse include in the plan of care?

Correct Answer is A

Explanation

The nurse is reviewing fetal and maternal circulation with a group of nursing students.Which statement by a student demonstrates a need for further clarification?

Correct Answer is B

Explanation

A 56-year-old menopausal woman reports to the registered nurse that she has been experiencing vaginal itching, burning, and an increase in vaginal infections over the past 3 years. What important factor should the nurse consider before responding to the client's concerns?

A nurse is caring for a postpartum client who reports feeling anxious, irritable, and unable to sleep despite extreme fatigue.The client also expresses feelings of inadequacy as a mother.Which of the following nursing interventions is the most appropriate initial action?

A male client reports to the nurse that he took sildenafil for erectile dysfunction but did not achieve an erection.Which of the following considerations should the nurse evaluate to determine possible reasons for the lack of response?

A nurse is reviewing the different signs of pregnancy with a client who is in her first trimester.Which of the following symptoms should the nurse classify as a positive sign of pregnancy?

A nurse is caring for a client who is 3 days postpartum and is attempting to breastfeed.Which of the following findings indicate mastitis?

A nurse is caring for a client at the first prenatal visit who has a BMI of 23.5. The client asks how much weight she should gain during pregnancy.Which of the following responses should the nurse make?

A nurse is assessing a postpartum client for signs of postpartum depression.Which of the following symptoms is most indicative of postpartum depression rather than normal postpartum adjustment?