A 28-year-old female presents to the obstetrics office, suspecting she may be pregnant. Which of the following would the nurse recognize as a presumptive sign of pregnancy?

Enlarged uterus.

Positive fetal cardiac activity on ultrasound.

Auscultation of fetal heart tones.

Amenorrhea.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Enlarged uterus is a probable sign of pregnancy, often caused by uterine growth. Probable signs are those observed by the examiner but not definite.

Choice B rationale

Positive fetal cardiac activity on ultrasound is a positive sign of pregnancy. Positive signs are definitive proof of pregnancy, observed via imaging or hearing fetal heart tones.

Choice C rationale

Auscultation of fetal heart tones is a positive sign of pregnancy, indicating fetal presence. Positive signs confirm pregnancy through direct observation or hearing the fetus.

Choice D rationale

Amenorrhea is a presumptive sign of pregnancy, commonly due to hormonal changes. Presumptive signs are subjective symptoms experienced by the woman, like nausea or breast tenderness.

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Correct Answer is A

Explanation

Choice A rationale

A reactive nonstress test is defined as having two or more fetal heart rate accelerations of at least 15 beats per minute lasting 15 seconds or more within a 20-minute period.

Choice B rationale

No late decelerations of the fetal heart rate do not define a reactive nonstress test, which focuses on fetal heart rate accelerations as indicators of fetal well-being.

Choice C rationale

The presence of late decelerations in more than 50% of contractions indicates uteroplacental insufficiency and fetal distress, not a reactive nonstress test which requires accelerations.

Choice D rationale

Fetal heart rate accelerations less than 15 beats per minute or lasting less than 15 seconds do not meet the criteria for a reactive nonstress test, which requires accelerations of 15 beats per minute lasting 15 seconds or more.

A. Listen to the fetal heart rate. B. Assess the client’s recent food and fluid intake. C. Check the client’s blood pressure and pulse. D. Turn the client to a lateral position.

Correct Answer is D

Explanation

Choice A rationale

Evaluating the fetal heart rate does not address maternal symptoms of supine hypotensive syndrome. Moving the client first corrects the underlying issue. Fetal evaluation can follow once maternal circulation improves, ensuring both are assessed.

Choice B rationale

Checking recent food and fluid intake does not immediately address the likely cause of supine hypotensive syndrome. Correcting maternal positioning is urgent to improve venous return and prevent adverse effects, then other assessments can follow.

Choice C rationale

Measuring blood pressure and pulse can confirm hypotension but does not address its cause. Immediate repositioning to lateral position alleviates the compression on the inferior vena cava, improving blood flow before measuring vitals.

Choice D rationale

Turning to a lateral position relieves the vena cava from compression by the gravid uterus, reducing symptoms of supine hypotensive syndrome. This action improves venous return, stabilizing maternal hemodynamics and alleviating dizziness and pallor.

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A 28-year-old female presents to the obstetrics office, suspecting she may be pregnant. Which of the following would the nurse recognize as a presumptive sign of pregnancy?

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Naxlex Comprehensive Predictor Exams

The nurse reviews a client’s antepartum nonstress test results as reactive. The nurse interprets this finding as:

Correct Answer is A

Explanation

The clinic nurse is measuring the uterine fundal height of a client at 36 weeks gestation lying in a supine position. The client suddenly reports dizziness, and the nurse observes pallor and damp, cool skin. What should the nurse do first?

Correct Answer is D

Explanation

A 28-year-old female presents to the obstetrics office, suspecting she may be pregnant. Which of the following would the nurse recognize as a presumptive sign of pregnancy?

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