The nurse in the prenatal clinic is triaging phone calls from pregnant clients.
Which client requires the most immediate response?
A client at 10 weeks gestation complaining of nausea and vomiting.
A client at 36 weeks gestation complaining of occasional uterine cramping.
A client at 14 weeks gestation complaining of thick white vaginal discharge.
A client at 28 weeks gestation complaining she has not felt her baby move.
The Correct Answer is D
Choice A rationale
Nausea and vomiting at 10 weeks gestation is a common physiological occurrence due to rising human chorionic gonadotropin (hCG) levels. While it requires assessment for hyperemesis gravidarum, it is rarely an immediate life-threatening emergency unless accompanied by severe dehydration, electrolyte imbalances, or inability to keep any fluids down for 24 hours. Normal potassium levels are 3.5 to 5.0 mEq/L. This client is stable compared to one with potential fetal demise or acute distress.
Choice B rationale
Occasional uterine cramping at 36 weeks gestation often represents Braxton Hicks contractions, which are irregular and non-productive. While the nurse must assess for signs of true preterm labor or placental issues, this is a common finding in the late third trimester as the body prepares for parturition. If the contractions are not increasing in frequency, duration, or intensity, and there is no vaginal bleeding, this client is considered a lower priority than a client reporting absent fetal movement.
Choice C rationale
Thick, white vaginal discharge during the second trimester is often indicative of leukorrhea or a yeast infection (Candidiasis). While uncomfortable and requiring treatment with antifungal agents, it does not pose an immediate threat to the mother or the fetus. The nurse should schedule an appointment for a vaginal swab and clinical evaluation, but this call does not take precedence over an urgent report of decreased fetal movement which may signal intrauterine hypoxia or fetal death.
Choice D rationale
A report of absent fetal movement at 28 weeks gestation is a critical red flag for potential fetal distress or intrauterine fetal demise. Fetal kick counts are a primary indicator of fetal well-being and oxygenation. After 24 to 28 weeks, the fetus should have a consistent movement pattern. Lack of movement requires immediate clinical evaluation via a non-stress test (NST) or biophysical profile to assess the fetal heart rate and placental perfusion. This represents the highest priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Erosive arthritis is not typically associated with Systemic Lupus Erythematosus (SLE). While many SLE patients experience joint pain and swelling known as lupus arthritis, it is characteristically non-erosive and non-deforming. This distinguishes it from rheumatoid arthritis, where the inflammatory process actively destroys bone and cartilage. In SLE, the joint involvement is usually transient and does not show the classic "punched-out" erosions on radiographic imaging, making this finding an unlikely or invalid sign for a typical SLE diagnosis.
Choice B rationale
Pericarditis is a well-recognized manifestation of Systemic Lupus Erythematosus and is the most common cardiac complication of the disease. It involves inflammation of the pericardium, the sac surrounding the heart, which can cause chest pain and a pericardial friction rub. Since SLE is a multisystem inflammatory disease that frequently targets serous membranes, the presence of pericarditis is highly consistent with the pathology of SLE and would be a valid sign found in a patient's medical record.
Choice C rationale
Photosensitivity is a classic and highly valid sign of Systemic Lupus Erythematosus. Approximately 60 to 90 percent of patients with SLE experience an abnormal reaction to ultraviolet (UV) light, which can trigger both skin rashes and systemic disease flares. UV exposure causes skin cell damage and the release of nuclear antigens that react with circulating antibodies, worsening the autoimmune response. Therefore, a history of skin reactions to sunlight is a key diagnostic criterion for the condition.
Choice D rationale
A red, macular facial rash, commonly known as the malar or "butterfly" rash, is the most iconic physical sign of Systemic Lupus Erythematosus. This rash typically spreads across the bridge of the nose and the cheeks while sparing the nasolabial folds. It is a valid clinical finding that appears in a large percentage of patients, particularly during periods of disease activity. Its presence is one of the primary physical markers used by clinicians to identify and monitor SLE.
Correct Answer is ["A","B","D","E"]
Explanation
Choice A rationale
Muscle weakening in bulimia nervosa stems from electrolyte imbalances and chronic dehydration caused by recurrent purging behaviors. Specifically, the loss of potassium through emesis or laxative abuse leads to hypokalemia, where serum potassium levels fall below the normal range of 3.5 to 5.0 mEq/L. Since potassium is essential for proper skeletal muscle contraction and electrochemical signaling, its depletion results in physical weakness and fatigue, which are common clinical manifestations in these patients.
Choice B rationale
Dental caries are a classic hallmark of bulimia nervosa due to the frequent exposure of tooth enamel to gastric acid during self-induced vomiting. The stomach acid has an extremely low pH, which chemically erodes the protective enamel and creates a high-acid environment that promotes tooth decay and cavities. This process, often referred to as perimylolysis, typically affects the lingual surfaces of the teeth and is an important physical indicator for nurses during a systemic assessment.
Choice C rationale
Lanugo is a fine, downy hair growth that is typically a diagnostic feature of anorexia nervosa rather than bulimia nervosa. It is a physiological adaptation to extreme malnutrition and the loss of subcutaneous fat as the body attempts to maintain core temperature and provide insulation. Since individuals with bulimia nervosa often maintain a weight within or near the normal range, they do not usually experience the severe thermoregulatory deficits that trigger the growth of lanugo.
Choice D rationale
Calluses on the hands, specifically over the knuckles or dorsal surface, are known as Russells sign. This physical manifestation occurs when a patient uses their fingers to induce the gag reflex for purging. Repeated friction and contact with the upper incisors during this process lead to skin thickening and scarring in that specific area. It is a highly specific physical finding that suggests the presence of self-induced vomiting behavior even when the patient denies purging.
Choice E rationale
Normal weight is a significant diagnostic differentiator for bulimia nervosa compared to other eating disorders. While patients with anorexia nervosa are significantly underweight, those with bulimia often stay within a normal body mass index range or may even be slightly overweight. This occurs because the binge-purge cycle does not always result in a net caloric deficit. Therefore, maintaining a normal weight does not rule out the disorder and is a common assessment finding in this population.
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