A woman comes to the clinic reporting a missed period, breast tenderness, nausea, and fatigue.

Her home pregnancy test was positive yesterday.

When documenting the assessment, which of her reported symptoms should the nurse categorize as presumptive signs of pregnancy? Select all that apply.

Amenorrhea.

Breast tenderness.

Frequent urination.

Positive urine pregnancy test.

Braxton Hicks contractions.

Answer and Explanation

Correct Answer : A,B,C

Choice A rationale

Amenorrhea, or the cessation of menses, is a classic presumptive sign of pregnancy because it is a subjective symptom reported by the patient. While it often indicates conception due to rising progesterone levels maintaining the endometrial lining, it can also be caused by stress, strenuous exercise, or endocrine disorders. Because it is not a definitive objective finding that can only be attributed to a fetus, it remains categorized as a presumptive rather than a probable or positive sign.

Choice B rationale

Breast tenderness is categorized as a presumptive sign because it is a subjective sensation reported by the woman. During early pregnancy, increasing levels of estrogen and progesterone cause vascular engorgement and ductal proliferation within the mammary tissue. While highly suggestive of pregnancy, this symptom can also occur during the luteal phase of the menstrual cycle or due to hormonal medications. Normal physiologic changes in the breasts are among the earliest indicators recognized by the mother.

Choice C rationale

Frequent urination is a presumptive sign of pregnancy because it is a subjective symptom that can be caused by various factors. In the first trimester, the enlarging uterus remains in the pelvic cavity and exerts direct pressure on the bladder, reducing its capacity. However, urinary frequency can also be a symptom of a urinary tract infection, increased fluid intake, or diabetes. Since it is not an exclusive indicator of a developing fetus, it is categorized as presumptive.

Choice D rationale

A positive urine pregnancy test is considered a probable sign of pregnancy rather than a presumptive one. This is because it is an objective laboratory finding that detects human chorionic gonadotropin (hCG). While hCG is primarily produced by the placenta, it can also be present in cases of hydatidiform mole or certain choriocarcinomas. Because the test measures a hormone rather than directly visualizing the fetus, it is not a positive sign, but it is more objective than presumptive signs.

Choice E rationale

Braxton Hicks contractions are categorized as a probable sign of pregnancy. These are painless, irregular contractions that can be felt through the abdominal wall by an examiner starting in the second trimester. They occur as the uterine muscles tighten to enhance blood flow to the placenta. Unlike presumptive signs, these are objective physical findings observed by a healthcare provider. However, they are not positive signs because they do not confirm the presence of a live fetus.

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Correct Answer is B

Explanation

Choice A rationale

In the context of labor and delivery, power refers specifically to the forces acting to expel the fetus from the uterus. This includes primary powers, which are involuntary uterine contractions that result in effacement and dilation of the cervix, and secondary powers, which involve the voluntary bearing-down efforts made by the mother. While power is essential for the progression of labor, it does not describe the anatomical positioning or orientation of the fetus itself.

Choice B rationale

The passenger refers to the fetus and the placenta. Fetal position, such as left occiput anterior, describes the relationship of a specific fetal landmark to the four quadrants of the mother's pelvis. This is a crucial component of the passenger variable because the way the fetus moves through the birth canal depends on its size, presentation, lie, and attitude. Assessing the passenger allows the healthcare team to predict the ease or difficulty of the descent during labor.

Choice C rationale

Passage refers to the maternal birth canal, which consists of the bony pelvis and the soft tissues of the cervix, pelvic floor, and vagina. While the dimensions and shape of the passage are vital for a successful delivery, this term does not describe the fetus. The nurse must distinguish between the container and the content. Understanding the passage involves clinical pelvimetry, but the fetal position remains a characteristic of the passenger navigating through that specific passage.

Choice D rationale

Psyche refers to the psychological and emotional state of the laboring woman. Factors such as anxiety, previous experiences, cultural expectations, and social support can influence how a woman perceives and manages the pain and stress of labor. Although the mother's psyche can impact the overall progress of labor by affecting hormonal balance and muscle tension, it is entirely distinct from the physical assessment of fetal position or the mechanical factors involving the fetus.

A. Frequency (how often contractions occur). B. Duration (how long each contraction lasts from beginning to end). C. Intensity (the strength of the contraction at its peak). D. Appearance (the shape and height on the monitor tracing).

Correct Answer is ["A","B"]

Explanation

Choice A rationale

Frequency is measured from the beginning of one contraction to the beginning of the next contraction. It is a critical component of labor documentation because it helps the nurse assess the progress of labor and the adequacy of uterine rest periods. Normal labor typically involves contractions occurring every 2 to 5 minutes. Monitoring frequency ensures that the uterus is not being overstimulated, which could compromise uterine blood flow and lead to fetal distress.

Choice B rationale

Duration refers to the length of a single contraction from its onset to its completion, usually measured in seconds. In active labor, contractions typically last 40 to 90 seconds. Documenting duration is essential for evaluating the efficiency of the uterine muscle in thinning and dilating the cervix. Excessively long contractions, lasting over 90 seconds, can reduce placental perfusion and oxygen delivery to the fetus, necessitating close monitoring and potential intervention by the healthcare provider.

Choice C rationale

Intensity represents the strength of the uterine muscle during the peak of a contraction. While external fetal monitors can track the timing of contractions, they cannot accurately measure the actual pressure or intensity in millimeters of mercury. Intensity is best assessed by manual palpation of the fundus or by using an internal intrauterine pressure catheter. Therefore, a nurse using only an external monitor cannot reliably document quantitative intensity, as external readings are influenced by maternal adipose tissue.

Choice D rationale

The appearance or height of the contraction waveform on an external fetal monitor strip is subjective and depends heavily on the tightness of the monitor belt and the thickness of the maternal abdominal wall. It does not provide a scientifically standardized measure of labor progress or uterine strength. Relying on the visual height of the tracing to document contraction characteristics is inaccurate. Nurses must focus on measurable data like frequency and duration rather than the visual scale.

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A woman comes to the clinic reporting a missed period, breast tenderness, nausea, and fatigue. Her home pregnancy test was positive yesterday. When documenting the assessment, which of her reported symptoms should the nurse categorize as presumptive signs of pregnancy? Select all that apply.

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Naxlex Comprehensive Predictor Exams

A nurse documents that a laboring woman's fetus is in the left occiput anterior (LOA) position. A nursing student asks which of the five Ps this assessment finding refers to. The nurse should explain that fetal position describes the:

Correct Answer is B

Explanation

A nurse is documenting a laboring woman's contractions using the external fetal monitor. Which contraction characteristics should the nurse include in the documentation? Select all that apply.

Correct Answer is ["A","B"]

Explanation

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A woman comes to the clinic reporting a missed period, breast tenderness, nausea, and fatigue.

Her home pregnancy test was positive yesterday.

When documenting the assessment, which of her reported symptoms should the nurse categorize as presumptive signs of pregnancy? Select all that apply.