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 B
Explanation
A. Prior to giving birth: The rubella vaccine is not recommended before delivery but after delivery and before hospital discharge to protect future pregnancies.
B. Prior to discharge from the hospital after giving birth: The MMR vaccine is given postpartum before discharge to women who are not immune to rubella. This ensures they are protected in future pregnancies, as the vaccine is contraindicated during pregnancy.
C. When she does not desire future pregnancies: Even if a woman desires no future pregnancies, it's still recommended to provide immunity against rubella to avoid complications related to the virus.
D. Two weeks before attempting pregnancy again: After receiving the MMR vaccine, a woman should wait at least one month (not two weeks) before attempting to become pregnant due to the live virus in the vaccine.
Correct Answer is A
Explanation
A. Prepare the client for admission to the hospital. A positive contraction stress test indicates that there are late decelerations of the fetal heart rate with contractions, suggesting that the fetus may not tolerate labor well. Hospital admission is often necessary for further monitoring and possible intervention.
B. Document the findings as expected in the client records. A positive contraction stress test is an abnormal finding, not an expected one. It indicates potential fetal distress and requires immediate attention.
C. Repeat the contraction stress test in 24 hr. If the test is positive, further immediate action is needed, such as close monitoring or possible delivery, rather than waiting 24 hours to repeat the test.
D. Check the client's cervix for dilation. While cervical dilation may be assessed if the client is in labor, this action does not address the immediate concern of fetal distress indicated by a positive contraction stress test.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.