A nurse is reviewing documentation for a newly admitted pregnant client. Which of the following findings constitutes a clinically positive sign of pregnancy. confirming the presence of a fetus rather than indicating a probable or presumptive state?
Subjective report of quickening at 18 weeks gestation in a multiparous client
A positive serum hCG level and Goodell's sign on pelvic exam
Visualization of the gestational sac by ultrasound at 5 weeks gestation
Fetal heart tones auscultated by Doppler at 11 weeks gestation
The Correct Answer is D
A. Subjective report of quickening at 18 weeks gestation in a multiparous client: Quickening, or maternal perception of fetal movement, is considered a presumptive sign of pregnancy because it is subjective and can be influenced by gastrointestinal activity or abdominal muscle contractions.
B. A positive serum hCG level and Goodell’s sign on pelvic exam: Both findings are classified as probable signs of pregnancy. While hCG indicates hormonal changes and Goodell’s sign reflects cervical softening, these findings may also occur due to other hormonal conditions.
C. Visualization of the gestational sac by ultrasound at 5 weeks gestation: The presence of a gestational sac alone is an early probable sign but not diagnostic of a viable pregnancy. A definitive, or positive, sign requires visualization of an embryo or detection of fetal cardiac activity on ultrasound.
D. Fetal heart tones auscultated by Doppler at 11 weeks gestation: Detection of fetal heart tones is a clinically positive sign of pregnancy, confirming the presence of a living fetus. This finding provides objective evidence of fetal life and distinguishes true pregnancy from other physiologic or hormonal changes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While a history of disordered eating can influence dietary behaviors, avoidance of dairy does not indicate Pica. Pica specifically involves consuming non-food substances, not simply avoiding certain foods.
B. Craving spicy or specific flavored foods is common in pregnancy due to hormonal changes and altered taste perception. This behavior does not meet the diagnostic criteria for Pica, as no non-nutritive substances are consumed.
C. Persistent ingestion of non-food items such as starch and dirt defines Pica. The compulsive and repetitive nature of these cravings supports the diagnosis, which is often associated with nutritional deficiencies like iron or zinc deficiency.
D. Food preferences and aversions are typical in pregnancy and reflect normal changes in appetite. A preference for high-carbohydrate foods is not indicative of Pica since it involves normal, nutritive items.
Correct Answer is ["On her left side"]
Explanation
Sleeping on the left side enhances venous return and optimizes uteroplacental blood flow by preventing compression of the inferior vena cava and aorta by the gravid uterus. This position promotes better oxygen and nutrient delivery to the fetus while reducing maternal hypotension, dizziness, and edema. Supine or right-side sleeping can impair circulation, leading to decreased cardiac output and fetal perfusion, especially in later pregnancy.
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