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. When the neonate responds to the mother by some signal, attachment behavior is stimulated in the mother.This is based on therooting reflex, which helps the baby find the breast or bottle to start feeding and also promotes bonding between the mother and the baby.
Choice A is wrong because acrocyanosis is a normal condition in newborns that causes bluish discoloration of the hands and feet due to poor circulation.It is not related to muscle tone or reflexes.
Choice B is wrong because myelinization of nerves is a process that occurs gradually during development and is not influenced by tactile stimulation.Myelin is a fatty substance that covers nerve fibers and helps them transmit signals faster and more efficiently.
Choice D is wrong because reflexes are involuntary movements or actions that do not depend on conscious thought or learning.They are not directly related to growth patterns, although they may indicate the health and development of the brain and nervous system.
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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