A patient makes an appointment at the prenatal clinic because she believes she might be pregnant.

Which assessment should the nurse identify as a presumptive sign of pregnancy?

Positive pregnancy test.

Cervical softening.

Amenorrhea.

Vagina appearing violet in color.

Answer and Explanation

The Correct Answer is C

Choice A rationale
A positive pregnancy test is a probable sign of pregnancy, not a presumptive one. Probable signs are observed by the healthcare provider and are strongly suggestive of pregnancy but could be caused by other conditions.
Choice B rationale
Cervical softening, also known as Goodell’s sign, is a probable sign of pregnancy that occurs around the 6-8th week of gestation. It is observed by the healthcare provider during a physical examination.
Choice C rationale
Amenorrhea, or the absence of menstruation, is a presumptive sign of pregnancy. Presumptive signs are those experienced by the woman, such as amenorrhea, fatigue, and increased urination. However, these signs are not definitive proof of pregnancy as they could be caused by other conditions.
Choice D rationale
A violet coloration of the vagina, known as Chadwick’s sign, is a probable sign of pregnancy that occurs around the 4th week of gestation due to increased blood flow. It is observed by the healthcare provider during a physical examination.

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Correct Answer is D

Explanation

Choice A rationale
While it’s true that the growing uterus can exert pressure on the stomach and cause symptoms such as heartburn, this is more common in the later stages of pregnancy, not as early as 12 weeks.
Choice B rationale
Increased progesterone production does cause decreased motility of smooth muscle during pregnancy. This can lead to a variety of gastrointestinal symptoms, including heartburn. However, this is not the primary cause of heartburn during pregnancy.
Choice C rationale
Retained bile in the liver does not typically result in heartburn. Bile is produced by the liver and aids in the digestion of fats. If bile is retained in the liver, it can lead to conditions such as cholestasis, but it is not a direct cause of heartburn.
Choice D rationale
Increased estrogen production does not directly cause an increase in the secretion of hydrochloric acid. However, the hormonal changes that occur during pregnancy, including increased levels of progesterone, can relax the lower esophageal sphincter. This relaxation can allow gastric acid to escape into the esophagus, causing heartburn.

A. A 26-year-old patient who experiences migraines at the start of each menstrual cycle. B. A 38-year-old patient who reports smoking one pack of cigarettes daily. C. A 32-year-old patient with benign breast disease. D. A 28-year-old patient with a history of pelvic inflammatory disease.

Correct Answer is B

Explanation

Choice A rationale
While migraines can sometimes be exacerbated by oral contraceptives, they are not a contraindication.
Choice B rationale
This is the correct answer. Smoking, especially over the age of 35, significantly increases the risk of serious cardiovascular side effects from oral contraceptive use.
Choice C rationale
Benign breast disease is not a contraindication for oral contraceptives.
Choice D rationale
A history of pelvic inflammatory disease is not a contraindication for oral contraceptives.

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A patient makes an appointment at the prenatal clinic because she believes she might be pregnant. Which assessment should the nurse identify as a presumptive sign of pregnancy?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a prenatal clinic is caring for a client who is at 12 weeks gestation. The client is curious about the cause of her heartburn. Which of the following responses should the nurse provide?

Correct Answer is D

Explanation

A nurse is considering contraceptive options for four patients. Which patient should the nurse identify as having a contraindication for oral contraceptives?

Correct Answer is B

Explanation

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A patient makes an appointment at the prenatal clinic because she believes she might be pregnant.

Which assessment should the nurse identify as a presumptive sign of pregnancy?