A client who is 4 weeks pregnant, is at the first prenatal visit and reports to the nurse the use of alcohol. Which of the following should the nurse educate the client about, to be a safe level of alcohol intake during pregnancy?

Explanation:

A. "This is a probable sign of pregnancy."

A probable sign of pregnancy is an objective finding observed by a healthcare provider that suggests the likelihood of pregnancy but does not confirm it definitively. Examples of probable signs include positive pregnancy tests (urine or blood tests), changes in the uterus (enlargement, softening), and changes in the cervix (Goodell's sign, Chadwick's sign). Sensations of fetal movement, such as the feeling of the baby moving, are actually presumptive signs of pregnancy rather than probable signs because they can have other explanations and are not definitive proof of pregnancy.

B. "This is a possible sign of pregnancy."

While sensations of fetal movement can be associated with pregnancy, they are more accurately classified as presumptive signs rather than possible signs. Possible signs typically refer to signs or symptoms that could be related to various conditions, including pregnancy, but do not specifically indicate pregnancy on their own. In this context, "possible" may not be as accurate as "presumptive" for describing fetal movement as a sign of pregnancy.

C. "This is a positive sign of pregnancy."

A positive sign of pregnancy is a definitive finding that confirms the presence of a fetus. Examples of positive signs include fetal heartbeat heard by Doppler or ultrasound, fetal movement felt by the healthcare provider (palpation), and visualization of the fetus on ultrasound. Sensations of fetal movement reported by the woman (quickening) are not considered positive signs because they can be subjective and may have other explanations, such as gas or muscle contractions.

D. "This is a presumptive sign of pregnancy."

A presumptive sign of pregnancy is a subjective sign reported by the woman that may indicate pregnancy but can also have other explanations. Examples include amenorrhea (missed periods), nausea and vomiting (morning sickness), breast changes, and sensations of fetal movement (quickening). Sensations of fetal movement are considered presumptive because they are subjective and can be caused by factors other than pregnancy, such as gas or muscle contractions.

Explanation:

A. Prepare the abdominal and perineal areas: While preparing the abdominal and perineal areas may be necessary for potential interventions, such as a cesarean section or vaginal examination, it is not the priority at this moment.

B. Witness the signature for informed consent for surgery: Obtaining informed consent for surgery is important, especially if surgical intervention is anticipated. However, the priority in this case is to stabilize the client's condition and address the potential causes of painless, bright red vaginal bleeding.

C. Insert an indwelling urinary catheter: Inserting an indwelling urinary catheter may be beneficial for monitoring urinary output and assessing fluid status. However, it is not the immediate priority compared to addressing the client's vital signs and managing potential causes of bleeding.

D. Initiate IV access: This is the correct answer. Given the client's large amount of painless, bright red vaginal bleeding, the priority is to establish IV access to administer fluids and possibly blood products if there is evidence of hypovolemia or hemorrhage. IV access will also allow for the administration of medications or other interventions as needed.