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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?

A.

"This is a positive sign of pregnancy.

B.

"This is a possible sign of pregnancy."

C.

"This is a presumptive sign of pregnancy."

D.

"This is a probable sign of pregnancy"

Answer and Explanation

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.


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Related Questions

Correct Answer is D

Explanation

A. The client will be asked to stimulate her nipples for 5 min during the test. Nipple stimulation is used during a contraction stress test, not a nonstress test. The nonstress test only monitors the fetal heart rate without inducing contractions.

B. The client will receive an ultrasound prior to the test. An ultrasound is not a routine part of a nonstress test. The nonstress test only involves monitoring the fetal heart rate using an external monitor.

C. An IV will be initiated prior to the test. An IV is not necessary for a nonstress test as it is a noninvasive procedure that only requires external monitoring of the fetal heart rate.

D. An external fetal monitor will be used to monitor the FHR. A nonstress test involves the use of an external fetal monitor to assess the fetal heart rate and its response to fetal movements. This helps determine fetal well-being.

Correct Answer is C

Explanation

A. Give herself a hypertonic enema the day before the procedure. A hypertonic enema is not required for an amniocentesis. In fact, enemas are not part of the preparation for this procedure.

B. Wash her abdomen with soap and water the morning of the procedure. While general hygiene is always recommended, specific cleansing of the abdomen is not necessary for an amniocentesis.

C. Empty her bladder immediately prior to the procedure. At 23 weeks of gestation, the bladder should be emptied to prevent accidental puncture during the amniocentesis.

D. Refrain from eating breakfast the day of the procedure. Fasting is not necessary for an amniocentesis; the client can eat normally before the procedure.

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