A woman is in her seventh month of pregnancy. She has been ...

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A woman is in her seventh month of pregnancy. She has been complaining of nasal con-gestion and occasional epistaxis. The nurse suspects that:
 
  a. This is a normal respiratory change in pregnancy caused by elevated levels of es-trogen.
  b. This is an abnormal cardiovascular change, and the nosebleeds are an ominous sign.
  c. The woman is a victim of domestic violence and is being hit in the face by her partner.
  d. The woman has been using cocaine intranasally.

Question 2

The nurse is working with a 3-year-old child in Bryant's traction for a fractured femur. A pain assessment scale, such as the Oucher scale, can be useful to the nurse caring for this child because the pain assessment scale:
 
  1. Provides continuity and consistency in assessing and monitoring the child's pain.
  2. Decreases anxiety in the child.
  3. Increases the child's comfort level.
  4. Reduces the child's fear of painful procedures.

[Expo]

Answer to Question 1

A

Feedback
A Elevated levels of estrogen cause capillaries to become engorged in the respira-tory tract. This may result in edema in the nose, larynx, trachea, and bronchi. This congestion may cause nasal stuffiness and epistaxis.
B Cardiovascular changes in pregnancy may cause edema in lower extremities.
C This determination cannot be made on the basis of the sparse facts provided. If the woman had been hit in the face, she most likely would have additional physical findings.
D This determination cannot be made on the basis of the sparse facts provided.

Answer to Question 2

1
Rationale:
1. The purpose of a pain assessment scale is to assess and monitor pain. The nurse can reduce anxiety or fear and increase the child's comfort level by implementing appropriate nursing interventions based on assessment scale data.
2. Using an assessment scale cannot reduce the child's anxiety.
3. Using an assessment scale cannot increase the child's comfort level.
4. Using an assessment scale cannot reduce the child's fear.

Chapter 43_LO04