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 D
Explanation
Choice A rationale
Obtaining a blood sample for complete blood count is crucial but secondary. The client’s low blood pressure and high heart rate indicate possible hypovolemia requiring immediate intervention to restore blood pressure and perfusion.
Choice B rationale
Infusing normal saline helps restore blood volume. However, it won't address supine hypotension syndrome, caused by uterine compression of the inferior vena cava, which necessitates repositioning the client first to improve hemodynamic stability.
Choice C rationale
Palpating the abdomen for contractions is important in assessing labor progress. Yet, it doesn't address the immediate hemodynamic instability caused by supine hypotension, which needs immediate correction to avoid fetal compromise.
Choice D rationale
Tilting the backboard laterally displaces the uterus off the inferior vena cava, alleviating supine hypotension syndrome. This improves maternal blood pressure and fetal perfusion, addressing the immediate hemodynamic instability effectively.
Correct Answer is C
Explanation
Choice A rationale
Caput succedaneum is a benign, self-limiting condition and does not require direct pressure. It resolves on its own within a few days after birth. Applying pressure may cause unnecessary discomfort to the newborn.
Choice B rationale
A STAT CT scan of the head is not necessary for diagnosing cephalhematoma, which is a localized collection of blood between the skull and periosteum. CT scans are typically reserved for more severe neurological concerns.
Choice C rationale
A cephalhematoma, characterized by swelling that does not cross suture lines, requires notification of the pediatrician. It may increase the risk of hyperbilirubinemia and needs monitoring for potential complications.
Choice D rationale
While assessing neurological vital signs every 4 hours is important for overall newborn care, it does not address the specific condition of cephalhematoma. The primary concern is monitoring for complications such as jaundice.
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