Some pregnant patients may complain of changes in their voice and impaired hearing. The nurse can tell these patients that these are common reactions to:

Correct Answer: C

Rationale: The correct answer is C) congestion and swelling, which occur because the upper respiratory tract has become more vascular. During pregnancy, hormonal changes lead to increased blood flow to mucous membranes, including those in the upper respiratory tract. This increased vascularity can result in congestion and swelling, leading to symptoms like changes in voice and impaired hearing. The physiological changes in pregnancy can affect various body systems, including the respiratory system. Option A is incorrect because decreased estrogen levels are not typically associated with changes in voice or impaired hearing during pregnancy. Option B is incorrect as displacement of the diaphragm primarily affects breathing patterns and may not directly cause changes in voice or hearing. Option D is also incorrect as increased blood volume in pregnancy is more closely related to cardiovascular changes and would not directly cause the symptoms described. Understanding the anatomical and physiological changes that occur during pregnancy is crucial for healthcare providers to effectively care for pregnant patients. Educating patients about these normal changes can help alleviate anxiety and ensure appropriate management of symptoms.

Correct Answer: B

Rationale: In the context of pregnancy, glycosuria, the presence of glucose in the urine, is considered a variation of normal. During pregnancy, hormonal changes can lead to increased glucose levels in the urine, even when blood glucose levels are within normal limits. This is due to the kidneys working harder to filter the increased blood volume during pregnancy. Glycosuria is commonly observed in pregnant women and is usually not a cause for concern unless accompanied by high blood glucose levels indicative of gestational diabetes. Proteinuria (option A) in pregnancy can indicate potential kidney issues or preeclampsia, a serious condition characterized by high blood pressure and organ damage. Bacteria in the urine (option C) can be a sign of urinary tract infection, which needs prompt treatment to prevent complications during pregnancy. Ketones in the urine (option D) can indicate inadequate carbohydrate intake or potential issues with diabetes management, which can have negative implications for both the mother and the developing fetus. Understanding the variations in normal findings during pregnancy is crucial for healthcare providers to monitor and manage maternal health effectively. Educating pregnant women about these nuances can empower them to recognize when to seek medical attention for any concerning symptoms or test results during their pregnancy.

Correct Answer: B

Rationale: Physiologic anemia during pregnancy occurs because of the dilution of hemoglobin concentration in the blood due to an increase in plasma volume that is greater than the increase in red blood cell mass. This is a normal adaptation to support the increased demands of the developing fetus and placenta. Option B is correct because it directly addresses this physiological process. Option A, inadequate intake of iron, is incorrect because although iron deficiency can contribute to anemia, physiologic anemia in pregnancy is primarily due to hemodilution rather than inadequate iron intake. Option C, the fetus establishing iron stores, is incorrect because fetal iron stores do not directly cause the physiologic anemia in the mother. Option D, decreased production of erythrocytes, is incorrect because while there is an increase in red blood cell production during pregnancy, it is not sufficient to compensate for the expanded plasma volume, resulting in relative anemia. Understanding the mechanisms of physiologic changes in pregnancy is crucial for healthcare professionals to provide appropriate care and support to pregnant individuals. It also highlights the importance of monitoring and managing maternal health to ensure the well-being of both the mother and the developing fetus.

Correct Answer: B

Rationale: The correct answer is B) Situation, background, assessment, and recommendation. This method, known as SBAR (Situation, Background, Assessment, Recommendation), is a widely recognized communication tool in healthcare settings to ensure effective and structured information sharing. In this context, Situation refers to the current status of the patient, Background provides relevant information about the patient's history or condition, Assessment includes the nurse's analysis of the situation, and Recommendation suggests the action to be taken or the next steps required. Option A is incorrect as it includes "Shift-end report" instead of "Situation" and lacks "Recommendation." Option C also includes "Shift-end report" and "Recommendation," but it lacks the crucial "Situation" element. Option D is incorrect as it introduces "actual nursing diagnoses" and "remedy," which are not part of the standard SBAR communication framework. Understanding and utilizing the SBAR method is crucial for effective communication in healthcare, ensuring that critical information is conveyed accurately, concisely, and consistently among healthcare professionals, ultimately leading to improved patient outcomes and safety.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Assessment. The nurse identifying congestion and wheezes in the patient's lungs is part of the assessment phase of the nursing process. Assessment involves collecting data about the patient's health status, which includes observing physical signs, symptoms, and gathering information to make a nursing diagnosis. Option A) Diagnosis is incorrect because it pertains to analyzing the data collected during assessment to identify the patient's health problems. In this case, the nurse has not yet reached the diagnosis phase. Option B) Evaluation is incorrect as it involves determining whether the interventions implemented have been effective in achieving the desired outcomes. The information provided in the question precedes the need for evaluation. Option D) Implementation is incorrect as it involves carrying out the nursing interventions based on the identified nursing diagnosis. The data collection described in the question occurs before the implementation of any interventions. Understanding the nursing process is fundamental for nurses to provide safe and effective care. The assessment phase is crucial as it forms the foundation for the subsequent steps, guiding the nurse in developing appropriate nursing diagnoses, planning interventions, and evaluating the outcomes. This question reinforces the importance of thorough assessment skills in nursing practice, especially in pediatric patients with respiratory conditions like pneumonia.