When auscultating the anterior thorax of a pregnant woman, the nurse notices the presence of a murmur over the second, third, and fourth intercostal spaces. The murmur is continuous but can be obliterated by pressure with the stethoscope or finger on the thorax just lateral to the murmur. The nurse interprets this finding to be:

Correct Answer: B

Rationale: In this scenario, the nurse is likely detecting a mammary souffle. A mammary souffle is a benign vascular murmur heard over the breasts of pregnant or lactating women. This type of murmur is usually continuous, can be obliterated by applying pressure just lateral to it, and is typically heard over the second to fourth intercostal spaces. It is considered a normal finding in pregnancy due to increased blood flow in the breasts. The other options can be ruled out based on the clinical presentation and characteristics of the murmur described. Aortic stenosis and aortic insufficiency murmurs are typically associated with different characteristics and locations. A patent ductus arteriosus murmur would have a different quality and location than what is described in the scenario. Understanding the various types of murmurs and being able to differentiate between them is crucial for healthcare providers working in obstetric settings. It helps in providing accurate assessments, appropriate interventions, and ensuring the well-being of both the pregnant woman and the fetus. Being able to identify benign conditions like mammary souffle can prevent unnecessary concern or intervention.

Correct Answer: D

Rationale: In this scenario, the correct answer is option D, which is to use ultrasound to verify cardiac activity. This is the most appropriate action to take when fetal heart tones are not heard at 22 weeks of pregnancy. Using ultrasound allows for a direct visualization of the fetus's heart activity, providing a more accurate assessment of the baby's well-being. Option A is incorrect because waiting 10 minutes and trying again without taking further action could delay necessary intervention if there is a serious issue with the fetus. Option B is incorrect as relying solely on the mother's perception of fetal movement may not provide a reliable indication of fetal well-being. Option C is also incorrect as simply waiting and trying again does not address the underlying reason for the inability to hear the fetal heart tones. From an educational standpoint, understanding the importance of utilizing technology like ultrasound in assessing fetal well-being is crucial for healthcare professionals caring for pregnant women. This question reinforces the significance of prompt and accurate assessment in detecting potential complications in early pregnancy, highlighting the need for appropriate interventions to ensure the best outcomes for both the mother and the baby.

Correct Answer: A

Rationale: The normal fetal heart rate falls between 110 and 160 beats per minute, so the nurse should document the results as within the normal range. There is no indication of fetal distress based on the heart rate provided. Verifying with the maternal pulse or having the patient change positions is unnecessary in this scenario.

Correct Answer: C

Rationale: The correct answer is C) Kegel exercises should be performed 50 to 100 times a day. This frequency is recommended to strengthen the pelvic floor muscles, which can help prevent urinary incontinence and support the increasing weight of the uterus during pregnancy. Option A is incorrect because while Kegel exercises do help strengthen pelvic floor muscles, their primary purpose is not to specifically keep the uterus strong during pregnancy. Option B is incorrect as it does not provide a specific frequency for performing Kegel exercises. Twice a day may not be sufficient to achieve the desired strengthening effects on the pelvic floor muscles. Option D is incorrect as it describes the technique of performing Kegel exercises, but it does not address the recommended frequency of performing these exercises. In an educational context, it is important for individuals, especially pregnant women, to understand the correct frequency of performing Kegel exercises to maximize their benefits. By doing Kegel exercises 50 to 100 times a day, individuals can effectively strengthen their pelvic floor muscles, which can contribute to better bladder control, support during pregnancy, and potentially easier labor and delivery.

Correct Answer: B

Rationale: In early pregnancy, complications can arise that require careful planning and consideration when providing care to the client. In this scenario, the correct answer is B) conflict with family over gender expression. This is the most appropriate problem for the nurse to address because conflicts with family over gender expression can significantly impact the emotional well-being and support system of the pregnant individual. It is crucial for the nurse to address and resolve these conflicts to ensure the overall health and safety of both the client and the developing fetus. Option A) conflict with gender identity is not directly related to the immediate care needs of the client in early pregnancy. While gender identity is an important aspect of holistic care, in this specific context, addressing conflicts over gender expression within the family is more urgent and relevant to the client's immediate well-being. Educationally, this question highlights the importance of assessing and addressing psychosocial factors that can impact a pregnant individual's health during early pregnancy. It emphasizes the role of the nurse in providing holistic care that goes beyond just physical health concerns and includes emotional and social support. By understanding and addressing family dynamics and conflicts, nurses can better support their clients through this crucial period in their lives.