The nurse teaches a pregnant woman about the presumptive, probable, and positive signs of pregnancy.
The woman demonstrates understanding of the nurse's instructions if she states that a positive sign of pregnancy is:.

Choice A rationale:

Some form of cancer. Rationale: Tender, enlarged, and warm cervical lymph nodes are indicative of infection or inflammation close to the site. Cancerous lymph nodes are usually painless and firm. In this case, the symptoms suggest an active immune response to infection or inflammation in proximity to the palpated lymph nodes.

Choice B rationale:

Local scalp infection common in children. Rationale: Local scalp infection, while possible, typically does not cause tender, enlarged, and warm cervical lymph nodes. These symptoms are more consistent with an active immune response to infection or inflammation in the area near the lymph nodes.

Choice C rationale:

Infection or inflammation distal to the site. Rationale: Symptoms such as tenderness, enlargement, and warmth in cervical lymph nodes indicate a local response to infection or inflammation close to the site. "Distal" refers to a location away from the affected area, making this choice inappropriate for the described symptoms.

Choice D rationale:

Infection or inflammation close to the site. Rationale: Tender, enlarged, and warm cervical lymph nodes suggest an active immune response to infection or inflammation in the vicinity. These symptoms are signs of localized inflammation and are commonly seen in conditions such as tonsillitis, pharyngitis, or other upper respiratory infections.

Choice A rationale:

Leaving the infant in the room with the mother may not be appropriate, especially given the difficult delivery and the risk of complications, such as hypoglycemia.

Choice B rationale:

Taking the infant immediately to the nursery without monitoring vital signs and glucose levels could lead to missed signs of distress or hypoglycemia.

Choice C rationale:

Performing a gestational age assessment is important, but the immediate concern for this infant is the risk of hypoglycemia due to macrosomia (large birth weight). This choice does not address the immediate issue at hand.

Choice D rationale:

The correct answer. Macrosomic infants, especially those born after a difficult delivery, are at risk of hypoglycemia due to the excessive insulin production in response to high blood glucose levels. It is crucial to monitor the infant's blood glucose levels frequently and observe closely for signs of hypoglycemia, such as jitteriness, poor feeding, and lethargy.