A woman who is trying to get pregnant tells the nurse that she was very disappointed several months ago when she was informed that her positive pregnancy test was a false positive. Which method of determining pregnancy provides the greatest degree of accuracy?
Visualization of implantation by vaginal ultrasound.
Maternal blood serum tests positive for alpha-fetoprotein.
Presence of amenorrhea for 2 months.
Reports feeling tired all of the time.
The Correct Answer is A
Choice A rationale
Visualization of implantation by vaginal ultrasound offers the highest accuracy in confirming pregnancy, as it directly visualizes the implanted embryo, eliminating errors associated with biochemical tests.
Choice B rationale
Maternal blood serum tests positive for alpha-fetoprotein do not confirm pregnancy. Alpha-fetoprotein is a marker used primarily for screening fetal abnormalities, not pregnancy determination.
Choice C rationale
The presence of amenorrhea for 2 months can suggest pregnancy but is not definitive due to other potential causes of missed periods, such as hormonal imbalances or stress, reducing its accuracy.
Choice D rationale
Reporting feeling tired all the time is a nonspecific symptom that can result from numerous conditions unrelated to pregnancy, making it an unreliable method for pregnancy determination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Postpartum preeclampsia symptoms include headache, nausea, dizziness, weakness, and visual disturbances due to increased blood pressure. Normal BP is <120/80 mmHg. Labs may show elevated liver enzymes and proteinuria.
Choice B rationale
Infections postpartum can cause fever, localized pain, and discharge but are less likely to present with headache, nausea, dizziness, and visual disturbances. Normal WBC is 4,000-11,000 cells/mcL.
Choice C rationale
Anemia due to blood loss may cause fatigue, dizziness, and weakness but usually doesn't present with headache and visual disturbances. Normal hemoglobin is 12-16 g/dL for women.
Choice D rationale
Normal postpartum fatigue generally doesn't include severe headache, nausea, dizziness, and visual disturbances. It is mainly characterized by tiredness and mild discomfort as the body recovers.
Correct Answer is C
Explanation
Choice A rationale
Glucose water may be soothing due to the sweet taste, but it does not address the immediate need to protect the circumcision site from infection and aid in healing.
Choice B rationale
Liquid acetaminophen provides pain relief, but it does not address the immediate need to protect the circumcision site. Pain management alone is not sufficient for postoperative care.
Choice C rationale
Applying petrolatum gauze dressings on the site prevents the wound from sticking to the diaper, reduces irritation, and protects against infection, promoting healing. This is a priority intervention post-circumcision.
Choice D rationale
While keeping the infant warm is important for comfort and stability, it does not directly address the need to care for the circumcision site to prevent complications and promote healing.
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