A client is at the antepartal clinic for a pregnancy test.Which finding, if present, would be considered a positive sign of pregnancy?

Quickening.

Uterine enlargement.

Urinary frequency.

Presence of human chorionic gonadotropin (hCG) in blood.

Answer and Explanation

The Correct Answer is D

The correct answer is choice D. Presence of human chorionic gonadotropin (hCG) in blood. This is a positive sign of pregnancy that can only be attributed to a fetus. hCG is a hormone produced by the placenta that can be detected in blood or urine tests.

Choice A. Quickening. This is a presumptive sign of pregnancy that is based on the woman’s report of feeling fetal movements in her lower abdomen. This can occur at 16 weeks for second time moms and around 20 weeks for first time moms. However, this sign is not conclusive as other conditions can cause similar sensations.

Choice B. Uterine enlargement. This is a probable sign of pregnancy that can be observed by the nurse or doctor through palpation. However, this sign does not mean 100% that a baby is growing in the uterus as it can be due to other causes such as fibroids or tumors.

Choice C. Urinary frequency. This is a presumptive sign of pregnancy that is based on the woman’s report of needing to urinate more often than usual. This can be caused by hormonal changes and increased blood volume during pregnancy. However, this sign is not definitive as other conditions such as urinary tract infections or diabetes can also cause frequent urination.

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Correct Answer is D

Explanation

The correct answer is choice D. Decreased respirations.Magnesium sulfate is a medication that can causerespiratory depression, which means it can slow down or stop breathing.

This is a serious side effect that needs to be monitored closely by the nurse.

Choice A is wrong because increased Babinski reflex is not a side effect of magnesium sulfate.

The Babinski reflex is a normal response in infants, but abnormal in adults.

It occurs when the big toe bends upward and the other toes fan out when the sole of the foot is stroked.Magnesium sulfate can causepoor reflexes, but not specifically the Babinski reflex.

Choice B is wrong because diarrhea is not a side effect of magnesium sulfate when given intravenously or intramuscularly.Diarrhea can occur when magnesium sulfate is taken orally as a laxative, but that is not the case in this question.

Choice C is wrong because tetany is not a side effect of magnesium sulfate.

Tetany is a condition that causes muscle spasms and cramps due to low levels of calcium in the blood.Magnesium sulfate can actually causehypocalcemia, which means low levels of calcium in the blood, but this does not usually result in tetany.Tetany is more likely to occur when there is low magnesium in the blood, which is calledhypomagnesemia.

A. Observe the patient for vaginal discharge of bright red blood. B. Assess the patient’s vaginal tone. C. Massage the patient’s perineum. D. Apply petrolatum to the patient’s perineum.

Correct Answer is D

Explanation

The correct answer is choice D. Apply petrolatum to the patient’s perineum.This is because petrolatum can help soothe and protect the perineal area, which may be swollen, bruised, or have stitches after a vaginal delivery.Applying petrolatum can also prevent the pad from sticking to the wound and causing more pain.

Choice A is wrong because observing the patient for vaginal discharge of bright red blood is not a specific action for perineal care.Bright red blood may indicate postpartum hemorrhage, which requires immediate medical attention.

Choice B is wrong because assessing the patient’s vaginal tone is not a priority action for perineal care.Vaginal tone may be reduced after childbirth due to stretching of the pelvic floor muscles, but this can improve with time and exercises.

Choice C is wrong because massaging the patient’s perineum is not recommended for perineal care.Massaging the perineum may cause more trauma and discomfort to the area, especially if there are stitches or hemorrhoids.Massaging the fundus (the top of the uterus) may be done to help it contract and prevent bleeding, but this is different from massaging the perineum.

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A client is at the antepartal clinic for a pregnancy test.Which finding, if present, would be considered a positive sign of pregnancy?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is receiving magnesium sulfate.Which side effect should the nurse monitor for with this patient?

Correct Answer is D

Explanation

During the postpartal admission assessment, the nurse notes that a patient’s perineum appears edematous and ecchymotic. Based on this finding, which action should the nurse take?

Correct Answer is D

Explanation

A client is to receive ferrous sulfate tablets. Which drink item will enhance the absorption of the medication?

A patient who is 17 weeks pregnant shares several pieces of information with the nurse. Which statement made by the patient would indicate the patient is at risk for having an infant with intrauterine growth retardation (IUGR)?

The mother visits her infant in the nursery. The nurse shows the mother how to place her finger in the palm of the baby’s hand so that the baby will squeeze her finger.This behavior on the nurse’s part reflects an understanding of which principle?

The nurse instructs a class of postpartum women on methods to avoid nipple soreness while breastfeeding. Which comment by a class participant indicates the need for further instruction?

A patient comes to the antepartal clinic for her visit and provides the nurse with information. What piece of information places this patient at high risk for exposure to teratogenic agents?

A nurse is caring for a patient who is receiving oxytocin injection intravenously for labor induction.The nurse should monitor this patient for which adverse effect of oxytocin?

A nurse is caring for a primigravida whose cervix is 2 cm dilated, 75% effaced, and the fetal presenting part is at +2 station. The patient says to the nurse, “I want an epidural now.Why won’t someone give me an epidural?” Which response is most appropriate for the nurse to make?