A nurse is assessing a client who may be pregnant. The nurse reviews the client's history for presumptive signs. Which signs would the nurse most likely note? Select all that apply.
Nausea
Abdominal enlargement
Positive pregnancy test
Braxton Hicks contractions
Amenorrhea
Correct Answer : A,B,C,E
Choice A Reason: Nausea is a common presumptive sign of pregnancy, especially in the first trimester. It is caused by hormonal changes and may be accompanied by vomiting.
Choice B Reason: Abdominal enlargement is another presumptive sign of pregnancy, as the uterus grows to accommodate the developing fetus. It may be noticeable as early as 12 weeks of gestation.
Choice C Reason: A positive pregnancy test is a presumptive sign of pregnancy, as it detects the presence of human chorionic gonadotropin (hCG), a hormone produced by the placenta. However, it is not a definitive sign, as it may be affected by other factors such as medications, tumors, or false positives.
Choice D Reason: Braxton Hicks contractions are not a presumptive sign of pregnancy, but a probable sign. They are irregular and painless contractions of the uterus that occur throughout pregnancy, but become more frequent and noticeable in the third trimester. They are also known as false labor contractions.
Choice E Reason: Amenorrhea, or the absence of menstrual periods, is a presumptive sign of pregnancy, as it indicates that ovulation has ceased. However, it is not a definitive sign, as it may be caused by other factors such as stress, illness, or hormonal imbalances.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because hemoconcentration by hypertension is a condition where the blood volume decreases and the blood pressure increases, leading to a higher hemoglobin level. A normal hemoglobin level for a pregnant woman in her second trimester is 10.5 to 14 g/dL. A hemoglobin level of 11 g/dL is within the normal range, not indicative of hemoconcentration.
Choice B Reason: This is incorrect because a multiple gestation pregnancy is a pregnancy with more than one fetus, such as twins or triplets. A multiple gestation pregnancy can cause a lower hemoglobin level due to increased blood volume and increased demand for iron. A hemoglobin level of 11 g/dL is not suggestive of a multiple gestation pregnancy.
Choice C Reason: This is incorrect because greater-than-expected weight gain is not directly related to the hemoglobin level. Weight gain during pregnancy depends on various factors such as pre-pregnancy weight, nutrition, physical activity, and genetics. A hemoglobin level of 11 g/dL does not reflect the weight status of the pregnant client.
Choice D Reason: This is correct because iron-deficiency anemia is a common type of anemia that occurs when the body does not have enough iron to produce enough red blood cells. Iron-deficiency anemia can cause a low hemoglobin level and affect the oxygen delivery to the tissues and the fetus. A hemoglobin level of 11 g/dL may indicate iron-deficiency anemia, especially if the client has other symptoms such as fatigue, weakness, pale skin, or cravings for non-food items. The nurse should confirm the diagnosis with further tests and recommend iron supplements and dietary changes to treat the condition.
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"C"}
Explanation
Choice A Reason: Preeclampsia is a condition in which a pregnant woman develops high blood pressure and proteinuria (protein in the urine). It can lead to serious complications such as eclampsia, which is seizures caused by preeclampsia, and HELLP syndrome, which is hemolysis, elevated liver enzymes, and low platelets. The main risk factor for preeclampsia is chronic hypertension, which means high blood pressure before pregnancy or before 20 weeks of gestation. Preeclampsia can be detected by measuring the blood pressure and urine protein level. Uric acid is not a reliable indicator of preeclampsia.
Choice B Reason: Gestational diabetes is the correct answer as explained above.
Choice C Reason: Eclampsia is a severe complication of preeclampsia that causes seizures and can be fatal for both the mother and the baby. It usually occurs after 20 weeks of gestation or during labor or postpartum. The main risk factor for eclampsia is preeclampsia, which means high blood pressure and proteinuria during pregnancy. Eclampsia can be prevented by treating preeclampsia with antihypertensive drugs and magnesium sulfate, which is a medication that prevents seizures. Magnesium sulfate can also lower the serum magnesium level, which is the amount of magnesium in the blood. However, magnesium level is not a diagnostic criterion for eclampsia.
Choice D Reason: Placenta previa is a condition in which the placenta covers part or all of the opening of the cervix. It can cause bleeding during pregnancy or delivery and can endanger both the mother and the baby. The main risk factor for placenta previa is previous cesarean section or other uterine surgery, which can cause scarring or damage to the uterine wall. Placenta previa can be detected by ultrasound, which is an imaging test that uses sound waves to create pictures of the uterus and placenta. Hemoglobin is not a relevant factor for placenta previa. Gestational diabetes is a condition in which a woman develops high blood sugar levels during pregnancy. It can cause complications for both the mother and the baby, such as macrosomia, hypoglycemia, and birth trauma. The main risk factor for gestational diabetes is glucose intolerance, which means the body cannot use glucose effectively. Glucose intolerance can be detected by measuring the serum glucose level, which is the amount of glucose in the blood.
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