A nurse is caring for a client who is at 41 weeks of gestation. The nurse should understand that which of the following findings can indicate a prenatal complication in this client?
Leukorrhea.
Shortness of breath.
Non-pitting ankle edema.
Blurred vision.
The Correct Answer is D
Choice A rationale
Leukorrhea, a normal vaginal discharge, increases during pregnancy due to hormonal changes. It's not indicative of prenatal complications at 41 weeks of gestation.
Choice B rationale
Shortness of breath is common in late pregnancy due to the enlarged uterus pressing against the diaphragm. It is not necessarily a sign of a prenatal complication at this stage.
Choice C rationale
Non-pitting ankle edema is often seen in late pregnancy due to fluid retention and increased pressure on the veins. It is typically benign and not a sign of serious complications.
Choice D rationale
Blurred vision can indicate a serious prenatal complication such as preeclampsia, which is characterized by high blood pressure and can pose significant risks to both mother and baby if not managed properly. .
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Correct Answer is D
Explanation
Choice A rationale
An apical pulse of 66/min is within the normal range and not indicative of postpartum hemorrhage, which would typically cause an elevated heart rate due to blood loss.
Choice B rationale
A temperature of 38.3°C (101°F) could indicate infection or inflammation but is not a direct sign of postpartum hemorrhage, which primarily involves significant blood loss.
Choice C rationale
Blood pressure of 156/80 mm Hg is elevated but not directly indicative of postpartum hemorrhage, which would typically result in a drop in blood pressure due to loss of blood volume.
Choice D rationale
A respiratory rate of 32/min is significantly elevated and can be a compensatory response to hypovolemia from postpartum hemorrhage. This response occurs as the body tries to increase oxygen delivery due to blood loss.
Correct Answer is C
Explanation
Choice A rationale
A weak cry is not a typical manifestation of neonatal abstinence syndrome (NAS). NAS usually presents with a high-pitched, persistent cry due to central nervous system irritability.
Choice B rationale
Decreased muscle tone is not common in NAS. Infants with NAS often exhibit hypertonia, characterized by increased muscle tone and rigidity.
Choice C rationale
This statement is correct because an exaggerated Moro reflex is a common sign of NAS, indicating central nervous system hyperactivity in response to withdrawal from maternal drugs.
Choice D rationale
An infant with NAS does not console easily. They are often difficult to soothe due to irritability and discomfort from withdrawal symptoms. .