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The nurse guides the woman into the examination room and asks her to remove her clothes and put on an examination gown with the front open.
The woman states "I have special undergarments that I do not remove for religious reasons.”. The most appropriate response from the nurse would be:

"Tell me about your undergarment. I'll explain the examination procedure and then we can discuss how you can have your examination comfortably.”.

"I'll ask the doctor to modify your examination.”.

"You can have your examination without removing all your clothes.”.

"What you just said sounds strange.”.

Answer and Explanation

The Correct Answer is A

Choice A rationale

This response demonstrates cultural humility and a patient centered approach by inviting the woman to share the significance of her religious undergarments. By explaining the examination procedure first, the nurse can collaborate with the patient to find a respectful compromise that maintains modesty while ensuring a thorough clinical assessment. This fosters a therapeutic relationship and respects the patient autonomy. Acknowledging religious practices is essential in providing holistic care and ensuring the patient feels safe and understood during a vulnerable exam.

Choice B rationale

Offering to ask the doctor to modify the examination before understanding the patient's specific needs or explaining the necessity of the exam is premature. It places the burden of cultural negotiation on the physician rather than the nurse, who should be the primary advocate for the patient's comfort. This response also assumes that a modification is the only solution, rather than finding a way to work with the patient's garments to achieve a standard, high quality medical examination.

Choice C rationale

Simply stating the patient can keep her clothes on might lead to an incomplete or medically insufficient examination. Certain parts of a gynecological or physical exam require specific access to provide accurate diagnostic information. Without first discussing the nature of the garments and the requirements of the procedure, this response could compromise the quality of care. It is better to have an open dialogue about how to achieve the necessary clinical exposure while maintaining the patient's required level of modesty.

Choice D rationale

Labeling a patient's religious or cultural practices as strange is nontherapeutic, judgmental, and culturally insensitive. This type of communication creates a barrier to care and may cause the patient to withhold information or avoid future medical encounters. Professional nursing standards require the delivery of care that is free from bias and respectful of diverse backgrounds. Effective nursing involves validating the patient's perspective rather than alienating them with derogatory language or a lack of empathy regarding their personal beliefs.

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Correct Answer is B

Explanation

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.

A. Alteration in the pattern of fetal movement. B. Edema in the ankles and feet at the end of the day. C. Constipation. D. Hair loss.

Correct Answer is A

Explanation

Choice A rationale

Fetal movement is a primary indicator of fetal well-being and placental function. A significant decrease or sudden change in the frequency and intensity of movements can signal fetal distress, hypoxia, or placental insufficiency. Nurses teach women to perform kick counts, typically expecting at least 10 movements within a 2-hour period. Any deviation from the established baseline for that specific fetus requires immediate medical evaluation via a non-stress test or biophysical profile to assess the intrauterine environment.

Choice B rationale

Dependent edema in the lower extremities is a common physiological finding in late pregnancy due to increased hydrostatic pressure in the legs and compression of the inferior vena cava by the uterus. While uncomfortable, it is usually not a danger sign if it resolves with elevation and is not accompanied by hypertension or proteinuria. Normal salt and water retention during the third trimester contributes to this. However, sudden edema of the face or hands would be a concerning sign.

Choice C rationale

Constipation is a frequent complaint during the third trimester resulting from high progesterone levels, which relax smooth muscles and slow intestinal peristalsis. The mechanical pressure of the enlarging uterus on the rectum also contributes to delayed transit time. While it can lead to discomfort and hemorrhoids, it is considered a common discomfort of pregnancy rather than a danger sign. It is managed with increased fluid intake, fiber-rich diets, and moderate physical activity to stimulate bowel movements.

Choice D rationale

Changes in hair growth cycles are common during and after pregnancy due to shifts in estrogen levels. During pregnancy, the high estrogen levels typically keep hair in the growing phase, leading to thicker hair, though some women may experience thinning due to stress or nutritional deficiencies. Significant hair loss is generally not classified as an acute danger sign of pregnancy complications like preeclampsia or preterm labor. It is usually a benign cosmetic concern that stabilizes after the postpartum period ends.

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The nurse guides the woman into the examination room and asks her to remove her clothes and put on an examination gown with the front open. The woman states "I have special undergarments that I do not remove for religious reasons.”. The most appropriate response from the nurse would be:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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The nurse guides the woman into the examination room and asks her to remove her clothes and put on an examination gown with the front open.
The woman states "I have special undergarments that I do not remove for religious reasons.”. The most appropriate response from the nurse would be: