The nurse is caring for a client who visits the prenatal clinic stating she thinks she may be pregnant because she is able to feel the baby move. Which of the following statements by the nurse is an appropriate response?

This is a probable sign of pregnancy."

"This is a positive sign of pregnancy."

"This is a possible sign of pregnancy."

"This is a presumptive sign of pregnancy."

Answer and Explanation

The Correct Answer is D

A. "This is a probable sign of pregnancy.": Probable signs include objective findings observed by the examiner—such as uterine enlargement, positive pregnancy test, or Hegar’s sign—but not felt by the client alone. Feeling fetal movement is subjective, not probable.

B. "This is a positive sign of pregnancy.": Positive signs are definitive indicators confirmed by the examiner, such as visualization of the fetus on ultrasound, detection of fetal heart tones, or palpation of fetal movements by the provider. The client’s perception alone does not confirm pregnancy.

C. "This is a possible sign of pregnancy.": The term “possible” is not a standard clinical classification. Pregnancy signs are categorized as presumptive, probable, or positive, so this terminology is inaccurate in describing clinical findings.

D. "This is a presumptive sign of pregnancy.": Feeling fetal movement (quickening) is considered a presumptive sign because it is subjective and experienced only by the woman. It suggests pregnancy but is not diagnostic, as similar sensations may occur due to gas or intestinal movement.

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Correct Answer is D

Explanation

A. Secondary dysmenorrhea: Although secondary dysmenorrhea involves painful menstruation caused by pelvic pathology, it is a broad term. Endometriosis is a specific cause of secondary dysmenorrhea, but the additional symptoms of infertility and dyspareunia suggest a more defined diagnosis.

B. Primary dysmenorrhea: Primary dysmenorrhea typically begins during adolescence and is caused by excessive prostaglandin production leading to uterine contractions. It does not usually worsen over time or cause infertility and pain during intercourse.

C. PMS: Premenstrual syndrome is characterized by mood swings, breast tenderness, bloating, and fatigue occurring before menstruation. It does not cause severe pelvic pain, dyspareunia, or infertility, which are hallmark features of endometriosis.

D. Endometriosis: Endometriosis occurs when endometrial tissue grows outside the uterus, leading to chronic inflammation, scarring, and adhesions. It commonly causes progressive dysmenorrhea, deep dyspareunia, chronic pelvic pain, and infertility, aligning closely with this patient’s symptoms.

A. Notify the healthcare provider, as this finding may be associated with congenital anomalies. B. Document the finding as normal and continue with routine newborn care. C. Apply warm compresses to the cord to promote circulation. D. Document the finding as abnormal and continue with routine newborn care.

Correct Answer is B

Explanation

A. Notify the healthcare provider, as this finding may be associated with congenital anomalies: Two arteries and one vein represent the normal anatomy of the umbilical cord. Notification is unnecessary unless only one artery (a single umbilical artery) is present, which could indicate possible congenital anomalies.

B. Document the finding as normal and continue with routine newborn care: The normal umbilical cord structure consists of two arteries that carry deoxygenated blood from the fetus and one vein that returns oxygenated blood to the fetus. This finding confirms a normal cord and requires no additional interventions beyond standard care.

C. Apply warm compresses to the cord to promote circulation: The umbilical cord no longer functions in circulation after birth. Applying warm compresses would serve no purpose and could introduce unnecessary risk of infection or injury to the cord stump.

D. Document the finding as abnormal and continue with routine newborn care: Labeling a normal finding as abnormal could lead to confusion in medical records and unnecessary evaluations. Proper documentation should accurately reflect the expected normal anatomy of two arteries and one vein.

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The nurse is caring for a client who visits the prenatal clinic stating she thinks she may be pregnant because she is able to feel the baby move. Which of the following statements by the nurse is an appropriate response?

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