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 C
Explanation
The correct answer is choice C. Reminding her that she should be happy that one child survived and is healthy is the least helpful nursing action in supporting the woman as she copes with her loss.
This statement minimizes her grief and implies that she should not feel sad about the deceased twin.
It also disregards her attachment to both babies and her need to mourn the loss of one of them.
Choice A is wrong because offering her the opportunity for counseling to help her grieve is a helpful nursing action that recognizes her emotional distress and provides her with professional support.
Choice B is wrong because encouraging the woman to hold the deceased twin as well as the living twin is a helpful nursing action that allows her to acknowledge and bond with both babies and to create memories that may facilitate healing.
Choice D is wrong because assisting the woman to take pictures of both babies is a helpful nursing action that provides her with tangible mementos of her twins and honors their
Correct Answer is A
Explanation
The correct answer is choice A. The newborn’s nostrils flare slightly during respiration.This is a sign of respiratory distress in a newborn.
Flaring nostrils indicate that the newborn is working hard to breathe and may not be getting enough oxygen.
Choice B is wrong because the newborn’s hands and feet are blue and feel cool.This is a normal finding called acrocyanosis, which occurs due to immature peripheral circulation.
It usually resolves within 24 to 48 hours after birth.
Choice C is wrong because the newborn’s eyes move randomly when his head is turned to the side.This is a normal finding called nystagmus, which occurs due to immature eye muscles and coordination.
It usually disappears by 6 months of age.
Choice D is wrong because the newborn’s tongue thrusts forward when it is lightly touched.This is a normal finding called the extrusion reflex, which helps the newborn to suck and swallow.
It usually fades by 4 months of age.
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