A nurse is caring for a female client who suspects she is pregnant.
Which question, if asked by the nurse, is consistent with signs of early pregnancy?
“Have you had any shortness of breath?”.
“Have you had any episodes of loss of consciousness?”.
“Have you had any spotting?”.
“Have you noticed any tenderness in your breasts?”.
The Correct Answer is D
The correct answer is choice D. “Have you noticed any tenderness in your breasts?”
Breast tenderness is one of the early signs of pregnancy that may occur as early as one to two weeks after conception. It is caused by hormonal changes that prepare the breasts for lactation.
Choice A is wrong because shortness of breath is not a sign of early pregnancy. It may occur later in pregnancy due to the growing uterus pressing on the diaphragm.
Choice B is wrong because episodes of loss of consciousness are not a sign of early pregnancy. They may indicate a serious condition such as anemia, dehydration, or hypoglycemia that requires medical attention.
Choice C is wrong because spotting is not a sign of early pregnancy.
It may be a sign of implantation bleeding, which occurs when the fertilized egg attaches to the lining of the uterus. However, implantation bleeding is usually much lighter and shorter than a normal period.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rubella immunization should be given in the early postpartum period.This is because rubella infection during pregnancy can cause serious birth defects or miscarriage, and rubella vaccine is contraindicated during pregnancy.Therefore, the best time to vaccinate a woman who is not immune to rubella is after she delivers her baby.
Choice B is wrong because gamma globulin is not effective for preventing rubella infection or congenital rubella syndrome (CRS).Gamma globulin is a preparation of antibodies that can provide temporary protection against some infections, but it does not induce lasting immunity.
Choice C is wrong because gamma globulin should not be given at the next visit for the same reason as choice B.Moreover, gamma globulin can interfere with the response to live vaccines such as rubella vaccine, so it should not be given within 3 months before or after vaccination.
Choice D is wrong because rubella immunization should not be given at the next visit or during pregnancy, as it can pose a risk to the fetus.Rubella vaccine is a live attenuated virus vaccine that can cross the placenta and infect the fetus.The risk of CRS from vaccination during pregnancy is low, but it cannot be ruled out completely.Therefore, women who receive rubella vaccine should avoid pregnancy for at least 4 weeks after vaccination.
Correct Answer is B
Explanation
The correct answer is choice B. The client should avoid sexual intercourse.Sexual intercourse may stimulate uterine contractions and increase the risk of preterm labor.The client should also avoid activities that may cause dehydration, infection, or stress.
Choice A is wrong because documenting urine output hourly is not necessary for a client with preterm labor who is discharged home.Urine output may be affected by hydration status, kidney function, or medication use, but it is not a reliable indicator of preterm labor.
Choice C is wrong because maintaining a darkened, quiet environment is not required for a client with preterm labor who is discharged home.The client may benefit from rest and relaxation, but there is no evidence that light or noise affects preterm labor.
Choice D is wrong because eating small, frequent meals is not specific to a client with preterm labor who is discharged home.Eating small, frequent meals may help with nausea, heartburn, or blood sugar control, but it does not prevent preterm labor.
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