A nurse in a prenatal clinic is caring for a client who believes she might be pregnant because she feels the baby moving.Which statement should the nurse make?
“This is a probable sign of pregnancy.”.
“This is a possible sign of pregnancy.”.
“This is a presumptive sign of pregnancy.”.
“This is a positive sign of pregnancy.”.
The Correct Answer is C
Choice A rationale
A probable sign of pregnancy includes objective signs observed by an examiner, such as changes in the pelvic organs, enlargement of the abdomen, and positive pregnancy test.
Choice B rationale
Possible signs of pregnancy are those that are subjective and reported by the patient, such as nausea, vomiting, and missed period. These signs could be due to other conditions.
Choice C rationale
Feeling the baby moving, also known as quickening, is a presumptive sign of pregnancy. These are changes felt by the woman herself and can be caused by other conditions.
Choice D rationale
Positive signs of pregnancy are those that are confirmed by the examiner and cannot be caused by any other condition. These include hearing the fetal heartbeat, visualizing the fetus, and feeling the baby move.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Assisting with amnioinfusion is not the first priority. Amnioinfusion is a procedure where a sterile solution is introduced into the uterus to increase the volume of fluid around the fetus. It is typically used in cases of oligohydramnios (low amniotic fluid) or to dilute thick meconium in the amniotic fluid.
Choice B rationale
Inserting a scalp electrode is not the first priority. A scalp electrode is a device used to monitor the fetal heart rate more accurately. It is usually used when external monitoring does not provide a clear reading or when there is a need for continuous detailed monitoring.
Choice C rationale
Changing the woman’s position is the correct action. Late decelerations in the fetal heart rate can be a sign of uteroplacental insufficiency, a condition where the placenta cannot deliver adequate oxygen to the fetus. Changing the woman’s position can improve placental blood flow and potentially improve the oxygen supply to the fetus.
Choice D rationale
Notifying the health care provider is important but not the first priority. The nurse should first attempt interventions such as changing the woman’s position to improve the fetal heart rate.
Correct Answer is A
Explanation
Choice A rationale
Cervical dilation is a positive sign of labor. During labor, the cervix dilates to allow the baby to pass through the birth canal. This is a definitive sign that labor is occurring.
Choice B rationale
Amniotic fluid in the vaginal vault could indicate rupture of membranes, but it does not confirm labor. Labor may or may not be present when the membranes rupture.
Choice C rationale
Pain above the umbilicus is not a typical sign of labor. Labor pain is usually felt in the lower back and lower abdomen.
Choice D rationale
Brownish vaginal discharge could be a sign of “bloody show,” which can occur as labor approaches. However, it does not confirm that labor is occurring.
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