The nurse is conducting an annual examination on a young female who reports her last menses was 2 months ago.
Although the client insists she is not pregnant due to a negative home pregnancy test, which assessment should the nurse prioritize to assess for a possible pregnancy?
A positive urine hCG.
Uterine size and shape changes.
A fetal heartbeat.
Chadwick's sign.
The Correct Answer is A
A positive urine hCG test is a priority assessment to assess for a possible pregnancy.
The human chorionic gonadotropin (hCG) hormone is produced by the placenta after implantation and can be detected in the urine of pregnant women.
A urine hCG test is a common method used to confirm pregnancy.
Choice B is not an answer because changes in uterine size and shape occur later in pregnancy and are not a priority assessment for early pregnancy detection.
Choice C is not an answer because a fetal heartbeat can usually be detected at around 6-7 weeks of pregnancy and is not a priority assessment for early pregnancy detection.
Choice D is not an answer because Chadwick’s sign, which refers to the bluish discoloration of the cervix, vagina, and vulva due to increased blood flow, occurs later in pregnancy and is not a priority assessment for early pregnancy detection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The purpose of administering vitamin K to a newborn following delivery is to prevent bleeding.
Vitamin K helps blood to clot and is essential in preventing serious bleeding in infants.
Choice A is not an answer because administering vitamin K does not prevent infection.
Choice B is not an answer because administering vitamin K does not prevent potassium deficiency.
Choice D is not an answer because administering vitamin K does not prevent hyperbilirubinemia.
Correct Answer is D
Explanation
A postpartum fever is defined as a temperature greater than 100.4 degrees F (38.0 degrees C) on at least two occasions.
These fevers cannot be ignored as they can represent serious infections. The first task is to identify the source.
Choice A is not correct because continuing to monitor for another hour may delay necessary treatment.
Choice B is not correct because administering an antipyretic may only treat the symptom and not address the underlying cause of the fever.
Choice C is not correct because assisting the client in ambulation does not address the underlying cause of the fever.
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