A nurse is educating a group of nursing students about the signs of pregnancy. Which of the following is considered a positive sign of pregnancy?
Positive urine pregnancy test
Fetal movement felt by the mother
Auscultation of fetal heart tones by Doppler
Breast tenderness and enlargement
The Correct Answer is C
A. Positive urine pregnancy test: A positive urine pregnancy test detects hCG but can be influenced by other conditions like trophoblastic disease. It is classified as a probable sign, not a definitive confirmation of pregnancy.
B. Fetal movement felt by the mother: Perception of fetal movement (quickening) is a presumptive sign. It is subjective and can be confused with other sensations, so it is not a reliable indicator of pregnancy.
C. Auscultation of fetal heart tones by Doppler: Hearing fetal heart tones is a positive sign of pregnancy. It provides objective evidence of a fetus, confirming the presence of life inside the uterus and ruling out other conditions.
D. Breast tenderness and enlargement: These are presumptive signs and can occur due to hormonal changes unrelated to pregnancy. They are common in the premenstrual phase and thus not diagnostic on their own.
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Related Questions
Correct Answer is D
Explanation
A. 1+ pitting sacral edema: Mild pitting edema is a common clinical feature of preeclampsia, especially in the lower extremities or sacral area due to fluid retention. This finding aligns with expected symptoms and is not inconsistent with the diagnosis.
B. 3+ protein in the urine: Significant proteinuria (≥300 mg/24 hr or ≥1+ on dipstick) is a key diagnostic criterion for preeclampsia. A 3+ result reflects marked protein loss and supports the diagnosis, not contradicts it.
C. Blood pressure 148/98 mm Hg: A systolic pressure ≥140 mm Hg or diastolic ≥90 mm Hg on two readings at least 4 hours apart confirms hypertension in pregnancy. This value fits the diagnostic criteria for preeclampsia.
D. Deep tendon reflexes of +1: Clients with preeclampsia often exhibit hyperreflexia (+3 or +4) due to CNS irritability. A reflex score of +1 is diminished and inconsistent with the expected heightened neuromuscular activity seen in preeclampsia.
Correct Answer is A
Explanation
A. It prevents the formation of Rh antibodies in mothers who are Rh negative: Rh(D) immunoglobulin works by preventing the maternal immune system from recognizing and forming antibodies against Rh-positive fetal red blood cells. This is essential to protect future pregnancies from hemolytic disease of the newborn.
B. It destroys Rh antibodies in mothers who are Rh negative: Rh(D) immunoglobulin does not destroy antibodies that have already formed. If sensitization has occurred, the immunoglobulin is ineffective. It is strictly a preventive measure, not a treatment for existing antibodies.
C. It prevents the formation of Rh antibodies in newborns who are Rh positive: Newborns do not form Rh antibodies in response to their own blood type. The immune response in question occurs in the Rh-negative mother, not in the Rh-positive infant. This statement reflects a misunderstanding of the immunologic mechanism.
D. It destroys Rh antibodies in newborns who are Rh positive: Rh(D) immunoglobulin does not act on the newborn’s immune system or antibodies. It functions solely in the maternal circulation to prevent maternal sensitization to fetal Rh-positive cells.
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