The nurse is assessing a client who reports they have missed three menstrual periods and now visits the prenatal clinic.
The client reports having enlarged breasts, urinary frequency, and nausea and is concerned that they may be pregnant.
What is the best response by the nurse?
It sounds like you are definitely pregnant.Congratulations!
You might be pregnant, but we will have to do a pregnancy test and measure your fundus to be sure.
These signs could be caused by other things, so we will need to hear the fetal heartbeat to be certain.
You should come back in 4 weeks to do further testing.
The Correct Answer is C
This question assesses the nurses ability to categorize signs of pregnancy as presumptive, probable, or positive. The nurse must apply knowledge of diagnostic criteria to explain why subjective symptoms are not definitive evidence of a developing fetus or pregnancy.
Choice A rationale
Presumptive signs like nausea and urinary frequency are subjective and can be caused by various conditions like infection or stress. Telling a client they are definitely pregnant based only on these symptoms is medically inaccurate and unprofessional.
Choice B rationale
A pregnancy test and fundal height are considered probable signs of pregnancy. While more objective than presumptive signs, they can still be influenced by other factors like molar pregnancies or tumors, thus they do not provide absolute certainty.
Choice C rationale
This is the best response because it acknowledges the clients symptoms while explaining that they are presumptive. Positive signs, such as hearing the fetal heartbeat, are the only definitive way to confirm a pregnancy is actually present.
Choice D rationale
Delaying assessment for four weeks is inappropriate when a client presents with missed periods and pregnancy symptoms. Immediate diagnostic steps are necessary to establish prenatal care, confirm the pregnancy, and rule out any potential ectopic or abnormal gestations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Neonatal transition assessment requires specific timing to evaluate extrauterine adaptation accurately. Knowledge of the APGAR scoring system, which measures heart rate, respiratory effort, muscle tone, reflex irritability, and color, must be applied to determine the infant's immediate clinical status.
Choice A rationale
While signs of distress require immediate intervention, APGAR scoring is a standardized tool used for all newborns regardless of clinical appearance. Waiting for distress ignores the preventive and baseline value of the scheduled one-minute and five-minute assessments.
Choice B rationale
Although providers may be present, the nurse often performs the APGAR assessment in the delivery room. Nurses are trained to evaluate the five parameters to determine if neonatal resuscitation protocols, such as positive pressure ventilation, are necessary.
Choice C rationale
Standard practice dictates APGAR scoring at one and five minutes after birth. A score of 7 to 10 is normal. If the five-minute score is < 7, assessments continue every five minutes for up to twenty minutes.
Choice D rationale
Assessing APGAR every fifteen minutes is not standard practice and would interfere with thermoregulation and bonding. Vital signs are monitored frequently during the first hour, but the specific APGAR tool is limited to the immediate transition.
Correct Answer is B
Explanation
Safe blood transfusion practices rely on understanding ABO and Rh factor compatibility. Knowledge of antigens and antibodies must be applied to prevent life-threatening hemolytic transfusion reactions, ensuring the recipient's immune system does not attack the donor's red blood cells.
Choice A rationale
Type O negative is the universal donor but can only receive O negative blood. Type A positive blood contains A antigens, which would trigger a hemolytic reaction in an O negative recipient who possesses anti-A antibodies.
Choice B rationale
AB positive is the universal recipient because it lacks anti-A and anti-B antibodies and has the Rh antigen. Therefore, B negative blood can be safely transfused as there are no antibodies to attack the donor cells.
Choice C rationale
An A positive recipient has anti-B antibodies. AB negative blood contains B antigens on the cell surface. Transfusing AB negative blood would cause the recipient's antibodies to attack the donor's B antigens, causing hemolysis.
Choice D rationale
An Rh-negative recipient, such as someone with B negative blood, will develop antibodies if exposed to Rh-positive blood. O positive blood contains the Rh antigen, making it incompatible for an Rh-negative individual due to sensitization..
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