A client tells the nurse that she thinks she is pregnant. Which sign or symptom provides the best indication that the client is pregnant?

Morning sickness.

Hegar's sign.

Amenorrhea.

Breast tenderness.

Answer and Explanation

The Correct Answer is C

A. Morning sickness: While morning sickness (nausea and vomiting) is a common symptom in early pregnancy, it is not the most reliable sign of pregnancy, as it can also occur with other conditions.

B. Hegar's sign: Hegar's sign, which is the softening of the lower uterine segment, is a probable sign of pregnancy but requires a clinical exam for confirmation. It is not as definitive as amenorrhea.

C. Amenorrhea: Amenorrhea, or the absence of menstruation, is one of the most reliable early signs of pregnancy. A missed period is often the first indication that a woman may be pregnant.

D. Breast tenderness: While breast tenderness can occur during pregnancy, it can also happen due to other factors such as hormonal changes, making it a less definitive sign of pregnancy compared to amenorrhea.

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Correct Answer is D

Explanation

A. A High-Fowler's with the arm on the operative side elevated on pillows: While elevating the arm is important, a high-Fowler's position may cause unnecessary strain on the surgical site and is not recommended for comfort and healing in the immediate postoperative period.

B. Semi-Fowler's with the arm on the operative side in a dependent position: Keeping the arm in a dependent position can increase the risk of swelling and lymphedema, which should be avoided after a mastectomy.

C. High-Fowler's with the arm on the operative side in a dependent position: The high-Fowler's position, combined with keeping the arm in a dependent position, would likely increase swelling and discomfort and is not recommended postoperatively.

D. Semi-Fowler's with the arm on the operative side elevated on pillows: The semi-Fowler's position is ideal for comfort and healing, and elevating the arm helps reduce the risk of lymphedema by encouraging proper drainage and circulation post-surgery. This is the most appropriate position to promote recovery.

A. Place an ice glove on the episiotomy for 20 minutes. B. Visualize the perineum and check the episiotomy. C. Administer the prescribed PRN analgesic. D. Instruct the client on the use of a sitz bath.

Correct Answer is B

Explanation

A. Place an ice glove on the episiotomy for 20 minutes: Ice can help reduce swelling and pain, but it is more appropriate as a secondary action after assessing the area. The nurse should first evaluate the condition of the episiotomy before deciding on the best intervention.
B. Visualize the perineum and check the episiotomy: The first step is to assess the episiotomy site to check for any signs of infection, excessive swelling, or other complications that might be causing the pain. This allows the nurse to determine the most appropriate treatment.
C. Administer the prescribed PRN analgesic: Administering pain medication may help alleviate discomfort, but it is essential to first evaluate the episiotomy site to rule out any potential issues before addressing the pain.
D. Instruct the client on the use of a sitz bath: A sitz bath can be helpful for comfort, but the nurse should first assess the episiotomy site to ensure there are no complications requiring immediate attention before recommending this intervention.

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A client tells the nurse that she thinks she is pregnant. Which sign or symptom provides the best indication that the client is pregnant?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

How should the nurse plan to position a client who has just undergone a radical mastectomy?

Correct Answer is D

Explanation

Prior to performing a postpartum assessment, the client tells the nurse, "I have pain in my stitches." The nurse knows that the client had a midline episiotomy. Which action should the nurse take first?

Correct Answer is B

Explanation

The nurse is preparing to teach a class on breast self-examination. In describing the "at-risk" individual, the nurse should describe which woman as having the highest risk of developing breast cancer?

A young married couple asks the nurse at a community outreach clinic for guidance about having children because the wife was born with a cleft lip and palate, and the husband has an uncle with a cleft lip. Which action should the nurse take?

Which assessment finding should the nurse expect when palpating the fundus immediately after delivery?

Exhibits The nurse reviews the client data. Complete the diagram by dragging from the choices area to specify what is occurring with the fetus, two actions the nurse should take to address the condition, and two parameters the nurse should monitor to assess progress.

Exhibits Which education by the nurse will help resolve the issue for the client? Select all that apply.

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Exhibits The nurse reviews the client data. Drag the Word Choices to complete the sentence. Abnormal FHR patterns can result in dropdown, dropdownanddropdown.