A nurse in a prenatal clinic is caring for a client who believes that she might be pregnant because she feels the baby moving. Which of the following statements should the nurse make?

"This is a probable sign of pregnancy."

"This is a possible sign of pregnancy."

"This is a positive sign of pregnancy."

"This is a presumptive sign of pregnancy."

Answer and Explanation

The Correct Answer is D

Explanation:

A. "This is a probable sign of pregnancy."

A probable sign of pregnancy is an objective finding observed by a healthcare provider that suggests the likelihood of pregnancy but does not confirm it definitively. Examples of probable signs include positive pregnancy tests (urine or blood tests), changes in the uterus (enlargement, softening), and changes in the cervix (Goodell's sign, Chadwick's sign). Sensations of fetal movement, such as the feeling of the baby moving, are actually presumptive signs of pregnancy rather than probable signs because they can have other explanations and are not definitive proof of pregnancy.

B. "This is a possible sign of pregnancy."

While sensations of fetal movement can be associated with pregnancy, they are more accurately classified as presumptive signs rather than possible signs. Possible signs typically refer to signs or symptoms that could be related to various conditions, including pregnancy, but do not specifically indicate pregnancy on their own. In this context, "possible" may not be as accurate as "presumptive" for describing fetal movement as a sign of pregnancy.

C. "This is a positive sign of pregnancy."

A positive sign of pregnancy is a definitive finding that confirms the presence of a fetus. Examples of positive signs include fetal heartbeat heard by Doppler or ultrasound, fetal movement felt by the healthcare provider (palpation), and visualization of the fetus on ultrasound. Sensations of fetal movement reported by the woman (quickening) are not considered positive signs because they can be subjective and may have other explanations, such as gas or muscle contractions.

D. "This is a presumptive sign of pregnancy."

A presumptive sign of pregnancy is a subjective sign reported by the woman that may indicate pregnancy but can also have other explanations. Examples include amenorrhea (missed periods), nausea and vomiting (morning sickness), breast changes, and sensations of fetal movement (quickening). Sensations of fetal movement are considered presumptive because they are subjective and can be caused by factors other than pregnancy, such as gas or muscle contractions.

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Correct Answer is A

Explanation

Explanation:

A. An excessive amount of amniotic fluid is present.

Polyhydramnios is defined as an excessive accumulation of amniotic fluid within the amniotic sac surrounding the fetus. This condition can occur due to various factors, including fetal abnormalities, maternal health conditions such as diabetes or gestational diabetes, multiple gestations (twins, triplets, etc.), or idiopathic causes where no specific underlying condition is identified. The increased volume of amniotic fluid can be detected through ultrasound examinations, where amniotic fluid index (AFI) measurements are taken to assess the quantity of fluid present. Polyhydramnios is typically diagnosed when the AFI exceeds a certain threshold.

B. The client is carrying more than one fetus.

While it's true that multiple gestations, such as twins or triplets, can sometimes lead to polyhydramnios, the presence of polyhydramnios does not automatically indicate a multiple pregnancy. Polyhydramnios can occur in singleton pregnancies as well, particularly due to other factors like fetal anomalies, maternal health issues, or idiopathic reasons.

C. The fetus is likely to have a congenital anomaly, be growth-restricted, or demonstrate fetal distress during labor.

Polyhydramnios can be associated with various fetal and maternal conditions, but it does not directly indicate specific fetal issues like congenital anomalies, growth restriction, or fetal distress during labor. However, polyhydramnios can sometimes coexist with these conditions or be a result of them. For example, certain fetal abnormalities, such as gastrointestinal obstructions, can lead to polyhydramnios due to impaired swallowing and absorption of amniotic fluid.

D. There is an elevated level of alpha-fetoprotein (AFP) in the amniotic fluid.

Elevated levels of alpha-fetoprotein (AFP) in the amniotic fluid are typically associated with neural tube defects (such as spina bifida) or abdominal wall defects (like gastroschisis or omphalocele) in the fetus. However, AFP levels are not directly related to the presence of polyhydramnios. AFP testing is usually done separately as part of prenatal screening tests to assess the risk of certain fetal abnormalities.

A. Placenta previa B. Incompetent cervix C. Abruptio placentae D. Prolapsed cord

Correct Answer is C

Explanation

Explanation:

A. Placenta previa:

Placenta previa is a condition where the placenta partially or completely covers the cervix. It typically presents with painless, bright red vaginal bleeding, especially after 20 weeks of gestation. However, it is not usually associated with sudden, continuous abdominal pain. Instead, placenta previa is known for painless bleeding episodes, which can be severe but intermittent. Therefore, placenta previa is less likely to be the cause of the client's sudden abdominal pain and bleeding in this scenario.

B. Incompetent cervix:

Incompetent cervix, also known as cervical insufficiency, is a condition where the cervix begins to dilate and efface prematurely, often leading to preterm birth. While incompetent cervix can result in painless vaginal discharge or light bleeding, it typically does not cause sudden, continuous abdominal pain and significant vaginal bleeding. Additionally, incompetent cervix is more commonly diagnosed earlier in pregnancy, usually in the second trimester. Therefore, it is less likely to be the cause of the client's symptoms in the third trimester.

C. Abruptio placentae:

Abruptio placentae refers to the premature separation of the placenta from the uterine wall before delivery. It is associated with sudden, severe abdominal pain and vaginal bleeding. The bleeding may be concealed (hidden behind the placenta) or external, depending on the degree of separation. Abruptio placentae is a medical emergency that requires prompt intervention to prevent complications for both the mother and fetus. Given the sudden onset of continuous abdominal pain and vaginal bleeding in a client with pregnancy-induced hypertension, abruptio placentae is the most likely complication in this scenario.

D. Prolapsed cord:

Prolapsed cord occurs when the umbilical cord slips through the cervix and becomes compressed during labor or before the presenting part of the fetus. While prolapsed cord can lead to vaginal bleeding, it is not typically associated with continuous abdominal pain. Instead, prolapsed cord may cause fetal distress due to cord compression, which can manifest as abnormal fetal heart rate patterns. However, in this scenario, sudden, continuous abdominal pain is a more prominent symptom, making abruptio placentae a more likely cause.

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A nurse in a prenatal clinic is caring for a client who believes that she might be pregnant because she feels the baby moving. Which of the following statements should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who was admitted to the maternity unit at 38 weeks of gestation and who is experiencing polyhydramnios. The nurse should recognize that this diagnosis means which of the following?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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