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

Answer and Explanation

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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Correct Answer is B

Explanation

A. Preterm labor: Preterm labor typically presents with regular uterine contractions, cervical changes, and possibly mild bleeding. This client has no contractions or uterine activity, making preterm labor less likely in this scenario.

B. Placenta previa: Placenta previa is characterized by painless, bright red vaginal bleeding in the second or third trimester. The absence of contractions and a soft, non-tender uterus are consistent with this condition. The history of bleeding at 29 weeks further supports this suspicion.

C. Placental abruption: Placental abruption usually presents with painful vaginal bleeding, a firm or tender uterus, and sometimes fetal distress. The lack of uterine tenderness or contractions makes abruption less likely in this case.

D. Vasa previa: Vasa previa involves fetal blood vessels crossing the cervical os and is typically associated with membrane rupture and rapid fetal deterioration. The fetal heart rate is normal, and there’s no mention of ruptured membranes, which makes this diagnosis unlikely.

A. Provide a dark, quiet environment. B. Assess respiratory status every 4 hr. C. Administer magnesium sulfate IV. D. Ensure that calcium gluconate is readily available. E. Evaluate neurologic status every 8 hr.

Correct Answer is ["A","C","D"]

Explanation

A. Provide a dark, quiet environment: A low-stimulation environment helps reduce central nervous system excitability in clients with severe gestational hypertension. Bright lights and noise can provoke neural irritation, increasing the risk for seizures. Creating a calm space supports neurologic stability.

B. Assess respiratory status every 4 hr: Magnesium sulfate can cause respiratory depression, and early signs may be missed with infrequent monitoring. Respiratory assessments should occur every 1 to 2 hours to detect changes promptly. Four-hour intervals are too wide to ensure safety.

C. Administer magnesium sulfate IV: Magnesium sulfate is used to prevent seizures by reducing neuromuscular activity and stabilizing the central nervous system. It is a standard medication for clients with severe gestational hypertension and requires close monitoring during administration.

D. Ensure that calcium gluconate is readily available: Calcium gluconate is the reversal agent for magnesium sulfate toxicity, which can lead to respiratory or cardiac complications. Keeping it at the bedside allows for immediate treatment if signs of toxicity occur. This ensures rapid response during emergencies.

E. Evaluate neurologic status every 8 hr: Clients with severe gestational hypertension need more frequent neurologic assessments to detect early signs of worsening condition. Eight-hour intervals are too infrequent to catch changes like headache, visual changes, or altered consciousness. Frequent checks help guide timely interventions.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is admitting a client who is at 37 weeks of gestation and diagnosed with severe gestational hypertension. Which of the following actions should the nurse expect to implement? (Select All that Apply.)

Correct Answer is ["A","C","D"]

Explanation

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