A nurse is assessing a client who is 6 months pregnant.Which findings should the nurse expect? (Select all four options that apply.)
hypoactive oil and sweat glands
increased skin pigmentation
Persistent migraine headaches
Facial edema
Melasma
Linea nigra
Correct Answer : B,D,E,F
A. Hypoactive oil and sweat glands: Pregnancy typically causes increased activity in oil and sweat glands, not decreased.
B. Increased skin pigmentation: Increased pigmentation is common during pregnancy, often affecting areas like the areolas and abdomen.
C. Persistent migraine headaches: While some women may experience headaches in pregnancy, they are not an expected or typical finding and may require further assessment.
D. Facial edema: Mild facial edema can occur as pregnancy progresses, especially due to increased blood volume and fluid retention.
E. Melasma: Melasma, or "mask of pregnancy," is a common finding characterized by dark patches on the face due to hormonal changes.
F. Linea nigra: Linea nigra is a dark line that often appears on the abdomen during pregnancy as a result of hormonal changes.
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Correct Answer is A
Explanation
A. Assessing visual acuity directly tests cranial nerve II (the optic nerve), which is responsible for vision.
B. Eliciting the gag reflex tests cranial nerves IX (glossopharyngeal) and X (vagus), not cranial nerve II.
C. Checking for pupillary response to light primarily assesses the function of cranial nerve II but is more associated with cranial nerve III (oculomotor) since it involves the constriction of the pupil. While relevant, it is not the best standalone action for assessing cranial nerve II specifically.
D. Observing for facial symmetry is associated with cranial nerve VII (facial nerve), not cranial nerve II.
Correct Answer is A
Explanation
A. Wheezes are continuous high-pitched sounds that occur during expiration (or sometimes inspiration) and are common in conditions like asthma due to narrowed airways.
B. Crackles are discontinuous sounds often described as popping or crackling and are not typically high-pitched.
C. Rhonchi are low-pitched, snoring-like sounds caused by the obstruction of larger airways and are not characterized as high-pitched.
D. Stridor is a high-pitched sound usually associated with upper airway obstruction and is not typically heard with asthma.