A client in her 10th week of pregnancy exhibits presumptive signs of pregnancy which may include which of the following? Select all that apply.
Urinary frequency.
Positive urine pregnancy test.
Breast changes.
Quickening.
Amenorrhea.
Correct Answer : A,C,D,E
Choice A rationale
Urinary frequency is a presumptive sign of pregnancy often caused by hormonal changes, particularly increased human chorionic gonadotropin (hCG) and progesterone, and pressure from the enlarging uterus on the bladder, leading to a reduced bladder capacity and increased renal blood flow and filtration rate.
Choice B rationale
A positive urine pregnancy test is a probable sign of pregnancy, as it is highly suggestive but not entirely conclusive. It detects the presence of human chorionic gonadotropin (hCG), which can also be elevated due to certain tumors or conditions other than a viable intrauterine pregnancy.
Choice C rationale
Breast changes, such as fullness, tenderness, and darkening of the areolae, are presumptive signs. These changes are stimulated early in pregnancy by elevated levels of estrogen and progesterone, preparing the mammary glands for lactation and causing vascular engorgement and glandular hyperplasia.
Choice D rationale
Quickening refers to the maternal perception of fetal movement, usually felt between 16 and 20 weeks gestation. Because it is a subjective sensation, it is classified as a presumptive sign; it could potentially be confused with peristalsis or gas in the abdomen.
Choice E rationale
Amenorrhea, the cessation of menstruation, is an early and very common presumptive sign of pregnancy. It is caused by the hormonal milieu, primarily the sustained production of progesterone by the corpus luteum, which prevents the shedding of the endometrial lining.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Fetal hypoxemia is a state of decreased oxygen in the fetal blood, which is a significant non-reassuring sign often leading to decreased variability or absent variability, typically due to fetal metabolic acidosis. However, fetal sleep cycles are the most frequent and common temporary cause of decreased variability observed during monitoring.
Choice B rationale
Umbilical cord compression typically results in variable decelerations, which are abrupt FHR decreases that vary in duration, intensity, and timing relative to contractions, rather than simply causing a decrease in baseline FHR variability. Variability reflects the interplay of the fetal sympathetic and parasympathetic nervous systems.
Choice C rationale
Altered cerebral blood flow, often related to hypoxemia or acidosis, affects the central nervous system centers that regulate the FHR, leading to non-reassuring changes such as minimal or absent variability. While a cause, it is less common than the physiological state of fetal sleep in labor.
Choice D rationale
Fetal sleep cycles are the most common and transient cause of a period of decreased variability, which is defined as an amplitude range of 5 beats/min or less. These cycles usually last 20 to 40 minutes, and the variability should return to moderate (6 to 25 beats/min) when the fetus wakes.
Correct Answer is B
Explanation
Choice A rationale
Passing the mucous plug (or bloody show) is a common sign of impending labor, often occurring days or weeks before labor onset, and does not in itself signify an emergency or mandate an immediate hospital visit for a 40 week patient. It is the loss of the cervical seal and indicates cervical change, but is not a definitive sign of active labor needing immediate evaluation.
Choice B rationale
A trickle of fluid leaking from the vagina in a term pregnancy could indicate premature rupture of membranes (PROM), where the amniotic sac has broken. This presents a risk of ascending intrauterine infection for the mother and fetus, and a risk of umbilical cord prolapse, necessitating immediate sterile speculum examination and fetal status evaluation at the hospital.
Choice C rationale
Irregular, short contractions that do not increase in frequency, duration, or intensity are characteristic of Braxton Hicks contractions (false labor), which are normal in the last weeks of pregnancy. The patient should be advised to monitor the contraction pattern for signs of true labor before presenting to the hospital.
Choice D rationale
Normal fetal movement is a sign of fetal well-being. At 40 weeks' gestation, the baby should still be actively moving. The nurse would only be concerned and instruct the patient to go to the hospital if she reported a decrease or cessation of fetal movement, indicating potential fetal distress or compromise.
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