A client informs the nurse that she believes she is pregnant.
Which sign or symptom is the best indicator that the client is pregnant?
Hegar’s sign.
Breast tenderness.
Amenorrhea.
Morning sickness.
The Correct Answer is C
Choice C rationale
Amenorrhea, or the absence of menstruation, is often the first and most reliable sign of pregnancy. If a woman is in her childbearing years and a week or more has passed without the start of an expected menstrual cycle, she might be pregnant.
Choice A rationale
Hegar’s sign is a physical examination finding that can be indicative of pregnancy. However, it is not typically used as the primary indicator of pregnancy because it requires a pelvic examination and is less reliable than other signs such as amenorrhea.
Choice B rationale
While breast tenderness can be a symptom of early pregnancy, it is not the most reliable indicator. Many other conditions or factors, such as hormonal fluctuations related to the menstrual cycle, can also cause breast tenderness.
Choice D rationale
Morning sickness, characterized by nausea and vomiting, is a common symptom of early pregnancy. However, not all pregnant women experience morning sickness, and it can also be caused by other conditions. Therefore, it is not the most reliable indicator of pregnancy.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While notifying the charge nurse about the patient’s condition is an important step, it is not the immediate action that should be taken in this situation. The priority is to address the tachysystolic or tetanic contractions and variable fetal heart decelerations, which are signs of potential fetal distress.
Choice B rationale
Discontinuing the oxytocin infusion is the correct action. Oxytocin is a hormone that stimulates uterine contractions during labor. If a patient begins to experience tachysystolic or tetanic contractions, which are excessively frequent or prolonged contractions, it could lead to fetal distress. Discontinuing the oxytocin can help reduce the frequency and intensity of the contractions.
Choice C rationale
Reducing the rate of the oxytocin infusion may not be sufficient in this situation. Tachysystolic or tetanic contractions with variable fetal heart decelerations are serious signs that require immediate action. Simply reducing the rate of the infusion may not alleviate these symptoms quickly enough.
Choice D rationale
Adjusting the position of the fetal monitor transducers would not address the issue of tachysystolic or tetanic contractions. While it is important to ensure accurate monitoring of the fetus, the priority in this situation is to address the potentially harmful contractions.
Correct Answer is B
Explanation
Choice A rationale
Leakage of clear fluid from the breasts towards the end of the second trimester into the third trimester is normal. This fluid is colostrum, a precursor to breastmilk, and its presence indicates breast development in preparation for lactation.
Choice B rationale
An average weight gain during pregnancy is 25 to 35 pounds. In the second trimester, a woman should be gaining about 1 pound per week. A weight gain of 20 pounds by 20 weeks indicates the client is on track or has even gained slightly more than expected. However, further evaluation is important as excessive weight gain in pregnancy might be indicative of underlying conditions such as preeclampsia or gestational diabetes.
Choice C rationale
Fetal movement, also known as quickening, is a normal and expected occurrence around 18-20 weeks' gestation. It is a positive sign of fetal development and well-being.
Choice D rationale
Fundal height is the measure from the pubic symphysis to the top of the uterus. It is an indicator of fetal growth. A fundal height of 20cm at 20 weeks gestation suggests the pregnancy is progressing normally and the baby is growing appropriately.
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