A nurse is collecting data from a client who is at 16 weeks of gestation and tells the nurse that she felt light fluttering in her stomach the prior day.
The nurse should use which of the following terms to document this finding?
Quickening.
Lightening.
Braxton Hicks contractions.
Chloasma.
The Correct Answer is A
Choice A rationale:
Quickening is the term used to describe the first noticeable fetal movements felt by the pregnant person. It is often described as a fluttering or bubbling sensation in the lower abdomen.
Quickening typically occurs between 16 and 22 weeks of gestation, with an average of 18 weeks. It is a normal and reassuring sign that the pregnancy is progressing well.
The sensation of quickening is caused by the fetus moving its arms and legs, as well as by its body turning and rotating within the amniotic fluid.
It is important to note that not all pregnant women experience quickening at the same time, and some women may not feel it at all.
However, in this case, the client is at 16 weeks of gestation, which is within the typical timeframe for quickening to occur. Moreover, the client's description of "light fluttering in her stomach" is consistent with the sensation of quickening.
Choice B rationale:
Lightening is the term used to describe the descent of the fetus into the pelvis in preparation for labor.
It typically occurs in the last few weeks of pregnancy, and is often accompanied by a feeling of increased pressure in the pelvis and bladder.
The client in this question is only at 16 weeks of gestation, so it is too early for lightening to have occurred.
Choice C rationale:
Braxton Hicks contractions are irregular, painless contractions of the uterus that can occur throughout pregnancy.
They are often described as a tightening or hardening of the uterus, and they may come and go over a period of several hours. Braxton Hicks contractions are not a sign of labor, but they can sometimes be mistaken for it.
The client in this question did not describe any contractions, so Braxton Hicks contractions are not a likely explanation for her symptoms.
Choice D rationale:
Chloasma is a skin condition that is characterized by brown patches on the face.
It is also known as the "mask of pregnancy" because it is more common in pregnant women. Chloasma is caused by hormonal changes during pregnancy, and it typically fades after delivery.
The client in this question did not describe any skin changes, so chloasma is not a likely explanation for her symptoms
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: Severe nausea and vomiting
While nausea and vomiting can be common in early pregnancy, including ectopic pregnancies, they are not specific indicators of an ectopic pregnancy.
Approximately 70-80% of pregnant women experience nausea and vomiting, regardless of the location of the pregnancy. Hence, the presence of severe nausea and vomiting alone would not definitively point towards an ectopic pregnancy.
Choice B: Uterine enlargement greater than expected for gestational age
In an ectopic pregnancy, the fertilized egg implants outside the uterus, typically in the fallopian tube. This means the uterus would not be expected to enlarge as it would in a normal intrauterine pregnancy. In fact, uterine size might be smaller than expected for gestational age in cases of ectopic pregnancy.
Choice C: Copious vaginal bleeding
While vaginal bleeding can occur in ectopic pregnancies, it's not always present and is not the most common initial symptom. When bleeding does occur, it's often lighter than a normal menstrual period and may be brown or dark in color.
Copious vaginal bleeding is more likely to occur in cases of miscarriage or other pregnancy complications.
Choice D: Pelvic pain
Pelvic pain is the most common and characteristic symptom of an ectopic pregnancy.
The pain is often described as sharp, stabbing, or cramping, and it may be localized to one side of the abdomen. The pain can be intermittent or constant, and it may worsen with activity or movement.
The pain is caused by the stretching of the fallopian tube as the ectopic pregnancy grows. In some cases, the pain can be severe enough to cause nausea and vomiting.
Therefore, pelvic pain is the most reliable finding that the nurse should expect in a client with a possible ectopic pregnancy at 8 weeks of gestation.
Correct Answer is A
Explanation
Choice A rationale:
Ovarian cysts are fluid-filled sacs that form on or within an ovary. They are a common condition, affecting up to 1 in 5 women at some point in their lives. While most ovarian cysts are benign (non-cancerous), they can sometimes cause symptoms, including pelvic pain.
Ultrasound is a common imaging test that uses sound waves to create pictures of internal organs. It can be used to detect ovarian cysts, which often appear as fluid-filled sacs on the ovary.
The presence of an ovarian cyst on ultrasound, combined with the patient's symptoms of lower abdominal pelvic pain, suggests that the patient is at risk of developing complications from the cyst. These complications can include: Rupture: A ruptured ovarian cyst can cause sudden, severe pain and bleeding.
Torsion: This is when a cyst twists on its stalk, cutting off its blood supply. Torsion can also cause severe pain and may require emergency surgery.
Choice B rationale:
Appendicitis is an inflammation of the appendix, a small, finger-shaped organ located in the lower right abdomen. It is a common cause of abdominal pain, especially in young adults.
However, the patient in this scenario is experiencing pain in the lower abdominal pelvic region, not specifically in the lower right quadrant. This makes appendicitis less likely.
Additionally, the patient does not have any other symptoms that are typically associated with appendicitis, such as fever, nausea, or vomiting.
Choice C rationale:
Endometriosis is a condition in which tissue that normally lines the uterus grows outside of the uterus. It can cause pain, especially during menstruation.
However, the patient in this scenario does not report cyclical pain, which is a hallmark symptom of endometriosis. Additionally, endometriosis is not typically associated with the presence of fluid-filled sacs on the ovaries.
Choice D rationale:
Pelvic inflammatory disease (PID) is an infection of the upper genital tract, including the uterus, fallopian tubes, and ovaries. It is often caused by sexually transmitted infections (STIs).
PID can cause pelvic pain, but it is also typically associated with other symptoms, such as fever, vaginal discharge, and irregular bleeding.
The patient in this scenario does not have any of these other symptoms, and her white blood cell count is not elevated, which makes PID less likely.
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