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"

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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Correct Answer is C

Explanation

A. "Initiate depot medroxyprogesterone 14 days after the client's first day of her menstrual cycle." Depot medroxyprogesterone (Depo-Provera) is usually initiated within the first 5 days of a client’s menstrual cycle to ensure the client is not pregnant. Initiating it 14 days after may not provide immediate contraceptive coverage.

B. "Administer depot medroxyprogesterone every 6 to 8 weeks." Depot medroxyprogesterone is administered every 12 weeks (3 months), not every 6 to 8 weeks, to maintain contraceptive efficacy.

C. "Give the medication intramuscularly." Depot medroxyprogesterone is administered as an intramuscular injection, typically in the deltoid or gluteal muscle, to ensure proper absorption and contraceptive effectiveness.

D. "Massage the site after you administer the medication." Massaging the injection site is not recommended as it could lead to the faster absorption of the medication, which may reduce its duration of effectiveness.

A. Severe nausea and vomiting B. Pelvic pain C. Uterine enlargement greater than expected for gestational age D. Copious vaginal bleeding

Correct Answer is B

Explanation

A. Severe nausea and vomiting: Severe nausea and vomiting are more characteristic of hyperemesis gravidarum, not ectopic pregnancy.

B. Pelvic pain: Ectopic pregnancy typically presents with pelvic pain, which may be sharp and localized due to the implantation of the embryo outside the uterus, commonly in the fallopian tube.

C. Uterine enlargement greater than expected for gestational age: In an ectopic pregnancy, the uterus may not enlarge as expected because the embryo is implanted outside the uterus.

D. Copious vaginal bleeding: Vaginal bleeding can occur, but it is usually minimal rather than copious. Severe bleeding may occur if the ectopic pregnancy ruptures.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a newly licensed nurse about the administration of depot medroxyprogesterone. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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