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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Introducing solid foods to a baby at 3 months old is not recommended. The American Academy of Pediatrics suggests exclusive breastfeeding for the first 6 months of life.
Choice B rationale
The American Dental Association recommends that a child is at least 6 months old before they start using fluoride supplements, and only if the child is at high risk for tooth decay and the primary drinking water source is deficient in fluoride.
Choice C rationale
Waiting to give fruit juice until a baby is 6 months old is a correct practice. The American Academy of Pediatrics recommends that fruit juice should not be introduced into the diet of infants before 6 months of age.
Choice D rationale
Introducing cow’s milk when a baby is 9 months old is not recommended. The American Academy of Pediatrics advises against introducing cow’s milk until a child is 12 months old.
Correct Answer is B
Explanation
Choice A rationale
Administering oxytocin infusion is usually done to stimulate uterine contractions and prevent postpartum hemorrhage. However, it’s not the first action to take when the client’s blood pressure is low.
Choice B rationale
Evaluating the firmness of the uterus is crucial in this situation. A soft or “boggy” uterus could indicate uterine atony, a condition that can lead to serious postpartum hemorrhage. This could be the cause of the client’s low blood pressure.
Choice C rationale
Initiating oxygen therapy by non-rebreather mask can help increase the client’s oxygen saturation levels, but it doesn’t address the underlying cause of the low blood pressure.
Choice D rationale
Obtaining a type and crossmatch is important if the client needs a blood transfusion. However, it’s not the first action to take. The nurse should first assess for possible causes of the low blood pressure.
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