A client informs the nurse that she believes she is pregnant.
Which sign or symptom is the best indicator that the client is pregnant?

Choice A rationale

While nausea and vomiting can occur in the postpartum period, they are not the highest priority for a client with a history of rheumatic fever and heart damage. These symptoms are usually self-limiting and can be managed with antiemetics.

Choice B rationale

Fluid volume excess is the highest priority for a client with a history of rheumatic fever and heart damage. Rheumatic heart disease can result in impaired heart function, making it difficult for the heart to handle increased fluid volumes that occur during pregnancy and the postpartum period. This can lead to heart failure.

Choice C rationale

While sleep deprivation can occur in the postpartum period, it is not the highest priority for a client with a history of rheumatic fever and heart damage. Adequate rest is important for recovery, but it does not directly address the client’s risk of heart failure.

Choice D rationale

While infection is a concern in the postpartum period, it is not the highest priority for a client with a history of rheumatic fever and heart damage. While infection can exacerbate heart failure, the immediate concern is managing the client’s fluid volume to prevent heart failure.

Choice A rationale

The eye ointment used in newborns is not intended to clear the infant’s vision.

Choice B rationale

The purpose of the eye ointment is not to dilate the pupil for visualization of the red reflex.

Choice C rationale

While the ointment does help prevent infections, it is not specifically targeted against herpes.

Choice D rationale

The primary purpose of the eye ointment is to prevent eye infections in newborns. This is particularly important as mothers who have a sexually transmitted infection (STI) can pass it to their newborns during childbirth, putting them at risk for an eye infection known as ophthalmia neonatorum (ON)1.