A nurse is assisting with a prenatal examination of a client who is at 8 weeks of gestation. The nurse notes that the client's vagina and vulva are a purplish color. The nurse should document this finding as which of the following?
Ballottement
Chadwick's sign
Hegar's sign
Chloasma
The Correct Answer is B
Chadwick's sign is a bluish or purplish discoloration of the cervix, vagina, and vulva that can occur during pregnancy. It is caused by increased blood flow and vascular changes in the area. It is considered a normal finding in early pregnancy and is often used as a sign to support the diagnosis of pregnancy.
Ballottement refers to a palpable rebound of the fetus when the examiner pushes on the mother's abdomen.
Hegar's sign is the softening and compressibility of the lower uterine segment, which can be felt during a bimanual examination.
Chloasma refers to the development of hyperpigmented patches on the face, often referred to as the "mask of pregnancy."
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
a.This is not recommended. The central tip of the finger is more sensitive and has more nerve endings, which can cause more pain. The recommended site for blood glucose testing is the side of the fingertip, as it is less sensitive and provides an adequate blood sample.
b. While it is not necessary to wear sterile gloves for routine capillary blood glucose monitoring, it is important to ensure that the nurse's hands are clean. Wearing clean gloves helps maintain infection control practices.
c. After puncturing the selected site, the nurse should gently squeeze the finger to create a small drop of blood. The first drop of blood should be wiped away, and subsequent drops should be used for the glucose test. This ensures that the sample is fresh and not contaminated with tissue fluid.
d.Keeping the finger in a dependent position (hanging down) helps improve blood flow to the fingertip, making it easier to obtain a sufficient blood sample. This can help ensure an accurate glucose reading.
Correct Answer is B
Explanation
It is important for the nurse to acknowledge the client's fears and show empathy toward them. By saying "This must be very frightening for you," the nurse validates the client's feelings and shows that they are being heard. Additionally, by suggesting that they talk more about it, the nurse can work towards building a therapeutic relationship with the client and gain more insight into their thought processes.
The other options are not appropriate because:
a. The nurse should not deny the client's beliefs or try to convince them that they are wrong. This can cause
the client to feel invalidated which may make them less likely to trust the nurse.
c. While it is important to understand the client's perspective, this question may come off as confrontational and accusatory.
d. Similarly, this question may be perceived as confrontational and may make the client defensive. It is important to approach the client with empathy and understanding rather than skepticism.
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