A primigravida calls the Labor & Delivery unit and tells the nurse that she is 39 weeks pregnant and that over the past few days, although her breathing has become easier, she now feels the urge to urinate more often and has more swelling in her ankles and feet.
The nurse tells the client that she is experiencing what is commonly called:
Goodell's sign.
Lightening.
Hegar's sign.
Quickening.
The Correct Answer is B
Choice A rationale
Goodell's sign is the softening of the cervix, usually occurring around the fourth to sixth week of pregnancy. It indicates early pregnancy but does not relate to the symptoms described by the client.
Choice B rationale
Lightening refers to the baby settling deeper into the pelvis, which often occurs a few weeks before labor in first-time pregnancies. This shift can make breathing easier and increase pressure on the bladder, causing frequent urination and increased swelling in the lower extremities.
Choice C rationale
Hegar's sign is the softening of the lower uterine segment, typically seen around the sixth to eighth week of pregnancy. It is an early sign of pregnancy and not related to the symptoms experienced by the client near term.
Choice D rationale
Quickening is the term used to describe the first movements of the fetus felt by the mother, usually occurring around 16 to 20 weeks of pregnancy. This does not correlate with the symptoms described by the client who is near term.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","F","G"]
Explanation
Choice A rationale
Respiratory rate of 8 breaths per minute indicates respiratory depression, a serious adverse effect of magnesium sulfate toxicity. Magnesium sulfate can depress neuromuscular transmission, leading to decreased respiratory effort and rate.
Choice B rationale
Blood pressure of 150/90 mmHg is not indicative of magnesium sulfate toxicity. Elevated blood pressure is a symptom of pre-eclampsia and not directly related to the adverse effects of magnesium sulfate. Therefore, it does not indicate toxicity.
Choice C rationale
Lung crackles are typically associated with fluid overload or heart failure rather than magnesium sulfate toxicity. While it is a serious condition, it is not specifically an adverse effect of magnesium sulfate.
Choice D rationale
Increase in fetal heart rate is not a common adverse effect of magnesium sulfate. Fetal heart rate changes are more commonly related to the underlying maternal condition or other medications used in pregnancy rather than magnesium sulfate.
Choice E rationale
Deep tendon reflexes would typically be decreased or absent in magnesium sulfate toxicity. Therefore, presence of deep tendon reflexes would not indicate an adverse effect of magnesium sulfate.
Choice F rationale
Confusion can occur due to central nervous system depression caused by high levels of magnesium sulfate. This is a significant adverse effect indicating possible toxicity.
Choice G rationale
Urine output of 30 mL in 2 hours suggests oliguria, which can be a sign of magnesium sulfate toxicity as the drug is excreted through the kidneys. Reduced urine output can indicate the kidneys are not clearing the drug efficiently, leading to toxicity.
Correct Answer is ["0.76"]
Explanation
Step 1 is 3800 grams × 0.1 mg/kg. 3800 grams × 0.1 mg/kg = 380 mg.
Step 2 is 380 mg ÷ 0.5 mg/mL. 380 mg ÷ 0.5 mg/mL = 760 mL. Final calculated answer: 0.76 mL. .
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