A nurse is caring for a client who tells the nurse that she thinks she might be pregnant because she is able to feel the baby move. Which of the following statements should the nurse make?
"This is a positive sign of pregnancy.
"This is a possible sign of pregnancy."
"This is a presumptive sign of pregnancy."
"This is a probable sign of pregnancy"
The Correct Answer is C
A. "This is a positive sign of pregnancy." A positive sign of pregnancy includes objective evidence such as fetal heartbeat, fetal movement felt by the examiner, or visualizing the fetus on an ultrasound.
B. "This is a possible sign of pregnancy." Possible signs refer to physical changes that could indicate pregnancy but are not definitive, such as breast changes or uterine enlargement.
C. "This is a presumptive sign of pregnancy." Feeling fetal movement (quickening) is considered a presumptive sign because it is subjective and reported by the client, which may indicate pregnancy but is not definitive.
D. "This is a probable sign of pregnancy." Probable signs are objective signs observed by the examiner, such as a positive pregnancy test or Chadwick’s sign, but still not conclusive for pregnancy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Location of the placenta: Heavy, painless vaginal bleeding without contractions is a classic sign of placenta previa, where the placenta is abnormally positioned near or over the cervix. An ultrasound is used to determine placental location.
B. Rh incompatibility: Rh incompatibility is not associated with heavy vaginal bleeding, and ultrasound is not used to diagnose it. A blood test is required to assess Rh status.
C. Fetal lung maturity: Fetal lung maturity may be assessed in certain situations, but this is not related to the client's bleeding. The immediate concern is placental location.
D. Frequency and duration of contractions: The client has no contractions, and contractions are not the cause of heavy bleeding in this case. The priority is identifying placental issues.
Correct Answer is A
Explanation
A. "You will need an immunization following delivery." A negative rubella titer indicates the client is not immune to rubella. Since the rubella vaccine is a live vaccine, it cannot be given during pregnancy but should be administered postpartum to protect the client and future pregnancies.
B. "You are immune to rubella." A negative rubella titer indicates the client is not immune to rubella.
C. "I will administer the rubella immunization to you today." The rubella vaccine cannot be administered during pregnancy due to the risk of congenital rubella syndrome in the fetus, as it is a live attenuated vaccine.
D. "You had the rubella infection as a child." A negative rubella titer means there is no immunity, so the client likely has not had the rubella infection or the immunity has waned.
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