During her gynecologic check-up, a 17-year-old girl states that recently she has been experiencing cramping and pain during her menstrual periods.
The nurse would document this complaint as.

Choice A rationale

A positive serum pregnancy test is considered a probable sign of pregnancy, not a positive sign. This test detects human chorionic gonadotropin, which is secreted by the trophoblast. While highly suggestive of pregnancy, false positives can occur due to certain medications, molar pregnancies, or choriocarcinoma. Positive signs are those that can only be attributed to the presence of a fetus. Normal serum beta-hCG levels in non-pregnant women are generally less than 5 mIU/mL, and levels rise rapidly following implantation.

Choice B rationale

Detection of the fetal heart rate via doppler ultrasound is a positive sign of pregnancy because it provides objective, undeniable evidence of a living fetus. At 10 weeks gestation, the fetal heart tones can often be heard using a sensitive doppler device. This sign is distinct from presumptive or probable signs as it cannot be mimicked by any other physiological condition. The normal fetal heart rate range is between 110 and 160 beats per minute, which is significantly faster than the maternal pulse.

Choice C rationale

Chadwick sign is a bluish-purple discoloration of the cervix, vagina, and labia caused by increased vascularity and pelvic congestion. This is categorized as a probable sign of pregnancy. While commonly seen in pregnancy, it is not definitive because other conditions that cause pelvic congestion can produce similar changes in tissue color. Probable signs are objective findings observed by a healthcare provider but do not provide absolute proof of a fetus. It typically appears around the sixth to eighth week of gestation.

Choice D rationale

Fatigue is a presumptive sign of pregnancy. Presumptive signs are subjective changes reported by the woman that could be caused by pregnancy but could also be attributed to many other factors, such as illness, stress, or lack of sleep. Other presumptive signs include nausea, breast tenderness, and amenorrhea. Because these symptoms are not specific to pregnancy, they are the least reliable indicators. In the first trimester, fatigue is common due to rising progesterone levels and metabolic changes occurring in the mother.

Choice A rationale

Inserting an internal monitor, such as a fetal scalp electrode or intrauterine pressure catheter, is an invasive procedure typically reserved for situations where external monitoring is inadequate or when the fetal status is non-reassuring. The description provided matches early decelerations, which are considered a benign finding. There is no clinical indication to move to internal monitoring when the current tracing shows a normal, expected physiological response to head compression during the active phase of labor.

Choice B rationale

The description of the fetal heart rate decelerating at the onset of contractions and returning to baseline before the contraction ends is the classic definition of early decelerations. These are caused by fetal head compression, which triggers a vagal response. They are considered a reassuring sign and do not indicate fetal distress or hypoxia. Therefore, the appropriate nursing action is to document the finding as a normal part of the labor process without requiring intervention.

Choice C rationale

Changing the woman's position is a common intervention for variable decelerations, which are caused by cord compression, or late decelerations, which are caused by uteroplacental insufficiency. However, early decelerations do not require intrauterine resuscitation because they are not associated with decreased fetal oxygenation. While frequent position changes are generally good for labor progress, it is not a required corrective action for early decelerations, as they are a normal physiological occurrence during fetal descent.

Choice D rationale

Discontinuing the Oxytocin infusion is an intervention used when there is tachysystole or a non-reassuring fetal heart rate pattern, such as repetitive late decelerations or prolonged decelerations. Since early decelerations are benign and signify head compression rather than fetal distress, there is no need to stop the induction. The nurse should continue to monitor the patient and the infusion, as the fetal heart rate pattern described does not indicate a need for emergency measures or cessation.