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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Related Questions
Correct Answer is B
Explanation
Choice A rationale
While the hepatitis B vaccine is an important part of preventing hepatitis B infection, it is not typically given on a monthly basis until the newborn tests negative for the hepatitis B surface antigen. Instead, the vaccine is usually given in a series of three to four doses over a six-month period.
Choice B rationale
For newborns who test positive for the hepatitis B surface antigen, the current recommendation is to administer both the hepatitis B immune globulin (HBIG) and the
hepatitis B vaccine within 12 hours of birth. The HBIG provides immediate, short-term protection against the virus, while the vaccine stimulates the newborn’s immune system to provide long-term protection.
Choice C rationale
While the hepatitis B immune globulin (HBIG) and the hepatitis B vaccine are both important for preventing hepatitis B infection in newborns, they are not typically administered in the manner described in this choice. The HBIG is usually given once, within 12 hours of birth, while the vaccine is given in a series of three to four doses over a six-month period.
Choice D rationale
The hepatitis B vaccine is typically given within 24 hours of birth, but it is not followed by doses of the hepatitis B immune globulin (HBIG) every 12 hours for three days. Instead, a single dose of HBIG is usually given within 12 hours of birth, along with the first dose of the vaccine.
Correct Answer is B
Explanation
Choice A rationale
Massaging the fundus is not necessary in this case. The fundus is firm, which indicates that the uterus is well contracted and there is no risk of postpartum hemorrhage. Massaging a well- contracted uterus can lead to uterine involution or even inversion.
Choice B rationale
Having the patient urinate is the correct action. A displaced fundus can be a sign of a full bladder. The bladder can push the uterus to the side and prevent it from contracting properly. By emptying the bladder, the uterus can return to its proper position and continue to contract to prevent bleeding.
Choice C rationale
Inserting a urinary catheter is not the first step. The nurse should first ask the patient to urinate. If the patient is unable to urinate, then a catheter may be necessary.
Choice D rationale
Administering an analgesic is not related to the position of the fundus. Pain management is important in postpartum care, but it is not the reason for a displaced fundus.
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