While assessing a pregnant primigravida client, the nurse identifies a probable sign indicating the softening of the lower uterine segment.
Which of the following signs is the nurse likely to have observed?
Quickening
Hegar’s sign
Braxton Hicks contractions
Ballottement
The Correct Answer is B
Choice A rationale
Quickening is the sensation of fetal movement by the pregnant woman. It usually occurs between 16 and 20 weeks of gestation.
Choice B rationale
Hegar’s sign is a probable sign of pregnancy that is characterized by the compressibility and softening of the cervical isthmus, which is the portion of the cervix between the uterus and the vaginal portion of the cervix. This sign typically presents between the fourth and sixth week of pregnancy. Therefore, if the nurse identifies a probable sign indicating the softening of the lower uterine segment, it is likely that the nurse has observed Hegar’s sign.
Choice C rationale
Braxton Hicks contractions are intermittent uterine contractions that occur during pregnancy. They are not a sign of labor and do not lead to cervical dilation or effacement. Therefore, they would not indicate the softening of the lower uterine segment.
Choice D rationale
Ballottement is a technique of palpating a floating structure by bouncing it and feeling it rebound. In the context of pregnancy, it refers to the movement of the fetus when the uterus is tapped during a pelvic examination. This does not indicate the softening of the lower uterine segment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A client diagnosed with preeclampsia reporting epigastric pain and unresolved headache is a serious concern. Epigastric pain could indicate severe liver involvement, and a persistent headache could be a sign of progressing neurological involvement, both of which are severe features of preeclampsia. These symptoms suggest the condition may be worsening to eclampsia, a life-threatening complication characterized by the onset of seizure activity or coma in a woman with preeclampsia. Immediate medical attention is necessary to prevent further complications.
Choice B rationale
A tearful client at 32 weeks of gestation experiencing irregular, frequent contractions could be experiencing preterm labor. However, emotional distress and contractions do not necessarily indicate a medical emergency. It’s important to monitor the situation, but it does not need to be immediately reported to the provider.
Choice C rationale
A client diagnosed with preeclampsia having 2+ proteinuria and 2+ patellar reflexes are expected findings. Proteinuria is a common sign of preeclampsia, and hyperreflexia can occur due to increased neuromuscular irritability. While these should be monitored, they do not need to be immediately reported to the provider.
Choice D rationale
A client at 28 weeks of gestation receiving terbutaline reporting fine tremors is an expected side effect of the medication. Terbutaline, a beta-adrenergic agonist, can cause tremors by stimulating the nervous system. While it may be uncomfortable for the client, it is not a medical emergency.
Correct Answer is B
Explanation
Choice A rationale
The term “passenger” in the context of the 5 P’s of labor refers to the fetus. The size, presentation, and position of the fetus can all affect the progress of labor. However, the provider’s comment about there being “plenty of room in the pelvis” does not directly relate to the fetus, so this is not the correct answer.
Choice B rationale
The term “passageway” refers to the birth canal, which includes the pelvis. The size and shape of the pelvis can greatly impact the progress of labor. If the provider comments that there is “plenty of room in the pelvis,” they are likely referring to the passageway. Therefore, this is the correct answer.
Choice C rationale
The term “powers” refers to the contractions during labor. The frequency, duration, and intensity of contractions can affect the progress of labor. However, the provider’s comment about there being “plenty of room in the pelvis” does not directly relate to contractions, so this is not the correct answer.
Choice D rationale
The term “position” refers to the mother’s position during labor. Different positions can help facilitate the progress of labor and can help with pain management. However, the provider’s comment about there being “plenty of room in the pelvis” does not directly relate to the mother’s position, so this is not the correct answer.
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