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 D

Explanation

Explanation:

A. Bowel sounds

While assessing bowel sounds is important in general nursing care, it is not the priority assessment when administering magnesium sulfate IV to a client in preterm labor. Bowel sounds can provide information about gastrointestinal function and potential complications like bowel obstruction or ileus. However, these assessments are not directly related to the immediate effects of magnesium sulfate on the client or fetus during preterm labor.

B. Temperature

Monitoring temperature is important to detect signs of infection, which could be a concern in any patient receiving IV medications. However, it is not the priority assessment when administering magnesium sulfate IV for preterm labor. The primary concern with magnesium sulfate is its effect on neuromuscular function and its potential impact on the fetus, making fetal heart rate monitoring a higher priority.

C. Respiratory rate

Assessing respiratory rate is crucial for monitoring respiratory status and detecting signs of respiratory distress or magnesium toxicity, which can affect respiratory function. While respiratory rate is an essential assessment, it is not the priority when administering magnesium sulfate IV for preterm labor. Fetal heart rate monitoring takes precedence due to the direct impact of magnesium sulfate on uterine contractions and fetal well-being.

D. Fetal heart rate (FHR)

Fetal heart rate monitoring is the priority nursing assessment when preparing to administer magnesium sulfate IV to a client experiencing preterm labor. Magnesium sulfate can affect fetal heart rate and overall fetal well-being, so continuous fetal heart rate monitoring allows the nurse to assess the baby's response to the medication and detect any adverse effects promptly. Monitoring FHR helps ensure the safety and well-being of the fetus during magnesium sulfate therapy.

A. Rh incompatibility B. Fetal gender C. Cephalopelvic disproportion D. Anomalies in fetal chromosomes E. Neural tube defects

Correct Answer is ["B","D","E"]

Explanation

Explanation:

A. Rh incompatibility

Amniocentesis is not used to identify Rh incompatibility. Rh incompatibility occurs when the mother is Rh-negative, and the baby is Rh-positive, leading to potential complications if the mother develops antibodies against the baby's Rh-positive blood cells. However, this condition is typically managed through other means such as Rh immunoglobulin (RhIg) administration.

B. Fetal gender

Amniocentesis can determine the fetal gender by analyzing the chromosomes present in the fetal cells obtained from the amniotic fluid. The presence of a Y chromosome indicates a male fetus, while its absence indicates a female fetus. Therefore, fetal gender can be identified through amniocentesis.

C. Cephalopelvic disproportion

Cephalopelvic disproportion refers to a situation where the baby's head is too large to pass through the mother's pelvis during childbirth. This condition is typically diagnosed during labor based on the progress of labor and fetal descent. Amniocentesis is not used to identify cephalopelvic disproportion.

D. Anomalies in fetal chromosomes

Amniocentesis is primarily used to identify anomalies in fetal chromosomes, such as chromosomal abnormalities like Down syndrome (Trisomy 21), Trisomy 18, and Trisomy 13. It can also detect other chromosomal abnormalities and genetic disorders caused by changes in the number or structure of chromosomes.

E. Neural tube defects

Amniocentesis can detect neural tube defects, such as spina bifida and anencephaly, by analyzing levels of alpha-fetoprotein (AFP) and other markers in the amniotic fluid. Elevated levels of AFP may indicate a neural tube defect.

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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 preparing to administer magnesium sulfate IV to a client who is experiencing preterm labor. Which of the following is the priority nursing assessment for this client?

Correct Answer is D

Explanation

A nurse is teaching a client who is at 15 weeks of gestation and is to undergo an amniocentesis. The nurse should explain that the purpose of this test is to identify which of the following conditions? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

A nurse in a prenatal clinic is caring for a client who is at 7 weeks of gestation. The client reports urinary frequency and asks if this will continue until delivery. Which of the following responses should the nurse make?

A nurse is caring for a client who is at 6 weeks of gestation with her first pregnancy and asks the nurse when she can expect to experience quickening. Which of the following responses should the nurse make?

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A nurse is completing a health history for a client who is at 6 weeks of gestation. The client informs the nurse that she smokes one pack of cigarettes per day. The nurse should advise the client that smoking places the client's newborn at risk for which of the following complications?

A nurse is teaching a client who is postpartum and has a new prescription for an injection of Rh, (D) immunoglobulin. Which of the following should be included in the teaching?

A nurse is caring for a client who has a suspected ectopic pregnancy at 8 weeks of gestation. Which of the following manifestations should the nurse expect to identify as consistent with the diagnosis?