The correct answer is choice A.

Choice A rationale:

Fetal heart tones detected by ultrasound are a positive sign of pregnancy because they provide direct evidence of a fetus.

Choice B rationale:

Breast tenderness is a presumptive sign of pregnancy, not a positive one, as it can be caused by other conditions such as premenstrual syndrome.

Choice C rationale:

A positive urine pregnancy test is a probable sign of pregnancy, not a positive one, as it measures the presence of hCG, a hormone produced during pregnancy. However, certain medications and medical conditions can also produce hCG.

Choice D rationale:

Fatigue is a presumptive sign of pregnancy, not a positive one, as it can be caused by various other conditions such as stress or illness.

The correct answer is choice A.

Choice A rationale:

An internal examination could disturb the placenta and cause profound bleeding, which is a life-threatening condition for both the mother and the fetus.

Choice B rationale:

While there is always a risk of introducing infection during an internal examination, this is not the primary reason to avoid it in a client with placenta previa.

Choice C rationale:

An internal examination could potentially initiate preterm labor, but this is not the primary concern with placenta previa.

Choice D rationale:

While there is a risk of rupture of the amniotic membranes during an internal examination, this is not the primary reason to avoid it in a client with placenta previa.

The correct answer is choice C.

Choice A rationale:

Keeping the baby’s head covered helps to prevent heat loss, as newborns lose a significant amount of heat through their heads.

Choice B rationale:

Keeping the baby’s bassinet away from fans and air conditioning helps to maintain a stable body temperature.

Choice C rationale:

Newborns’ temperatures are typically checked every 3 to 4 hours, not every hour, and are usually done axillary, not rectally.

Choice D rationale:

Placing the baby on the mother’s stomach and covering her with a warm blanket promotes skin-to-skin contact and helps to maintain the baby’s body temperature.

The correct answer is choice D.

Choice A rationale:

Cervix dilation of 5 cm with 50% effacement is a sign of active phase of the first stage of labor, not the end of it.

Choice B rationale:

Rupturing of fetal membranes can occur at any time during labor, not specifically at the end of the first stage.

Choice C rationale:

Start of regular contractions is a sign of the onset of labor, not the end of the first stage.

Choice D rationale:

Cervix dilation of 10 cm with 100% effacement indicates the end of the first stage of labor and the beginning of the second stage.

The correct answer is choice B.

Choice A rationale:

Stimulating the infant to cry is important, but it is not the first action to be taken.

Choice B rationale:

Clearing the respiratory tract is the first action to be taken to ensure the newborn can breathe properly.

Choice C rationale:

Drying the infant off and covering the head is done after the respiratory tract is cleared.

Choice D rationale:

Cutting the umbilical cord is done after the infant is stabilized.

The correct answer is choice C.

Choice A rationale:

Sitz baths cause perineal vasodilation, not vasoconstriction, and this does not directly affect bleeding.

Choice B rationale:

The duration of a sitz bath does not necessarily correlate with its therapeutic effect.

Choice C rationale:

Sitz baths increase the blood supply to the perineal area, promoting healing and providing relief from discomfort.

Choice D rationale:

Sitz baths do not increase the risk of postpartum infection when done properly.

The correct answer is choice D. When the cervix is fully dilated.

Choice A rationale:

The arrival of the health care provider does not determine when the laboring client should push. This is dependent on the dilation of the cervix.

Choice B rationale:

Seeing the fetal head is not the determinant for when the laboring client should push. The cervix needs to be fully dilated.

Choice C rationale:

The nurse wanting the client to push is not the correct time for the laboring client to push. The cervix needs to be fully dilated.

Choice D rationale:

The laboring client is encouraged to push when the cervix is fully dilated. This is to avoid birth trauma.

The correct answer is choice A. She did her perineal care independently.

Choice A rationale:

Taking the initiative for caring for her newborn independently while managing her own postpartum needs marks the taking-hold phase of infant bonding.

Choice B rationale:

Being eager to talk about her birth experience is more associated with the taking-in phase, not the taking-hold phase.

Choice C rationale:

Not asking for anything for pain all day is not a specific indicator of the taking-hold phase.

Choice D rationale:

Sitting and rocking her infant for long intervals is not a specific indicator of the taking-hold phase.

The correct answer is choice A. She did her perineal care independently.

Choice A rationale:

Taking the initiative for caring for her newborn independently while managing her own postpartum needs marks the taking-hold phase of infant bonding.

Choice B rationale:

Being eager to talk about her birth experience is more associated with the taking-in phase, not the taking-hold phase.

Choice C rationale:

Not asking for anything for pain all day is not a specific indicator of the taking-hold phase.

Choice D rationale:

Sitting and rocking her infant for long intervals is not a specific indicator of the taking-hold phase.

The correct answer is choice A.

Choice A rationale:

The glucose challenge test is used to check for gestational diabetes during pregnancy. People at average risk of gestational diabetes usually have this test done during the second trimester, generally between 24 and 28 weeks of pregnancy.

Choice B rationale:

This is too early in the pregnancy to screen for gestational diabetes. The body’s response to sugar changes as the pregnancy progresses, so testing is typically done later.

Choice C rationale:

This is still a bit early for the screening. The recommended time is between 24 and 28 weeks of gestation.

Choice D rationale:

This is too late in the pregnancy for the screening. The recommended time is between 24 and 28 weeks of gestation.