A nurse in a prenatal clinic is caring for a client who believes she might be pregnant because she feels the baby moving.Which statement should the nurse make?
“This is a probable sign of pregnancy.”.
“This is a possible sign of pregnancy.”.
“This is a presumptive sign of pregnancy.”.
“This is a positive sign of pregnancy.”.
The Correct Answer is C
Choice A rationale
A probable sign of pregnancy includes objective signs observed by an examiner, such as changes in the pelvic organs, enlargement of the abdomen, and positive pregnancy test.
Choice B rationale
Possible signs of pregnancy are those that are subjective and reported by the patient, such as nausea, vomiting, and missed period. These signs could be due to other conditions.
Choice C rationale
Feeling the baby moving, also known as quickening, is a presumptive sign of pregnancy. These are changes felt by the woman herself and can be caused by other conditions.
Choice D rationale
Positive signs of pregnancy are those that are confirmed by the examiner and cannot be caused by any other condition. These include hearing the fetal heartbeat, visualizing the fetus, and feeling the baby move.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.42"]
Explanation
Step 1: Convert grams to milligrams: 3 g = 3000 mg Step 2: Find out how many milligrams are in each milliliter: 3000 mg ÷ 5 mL = 600 mg/mL Step 3: Calculate how many milliliters to administer for a 250 mg dose: 250 mg ÷ 600 mg/mL = 0.42 mL So, the nurse should administer
0.42 mL of the antibiotic per dose.
Correct Answer is C
Explanation
The correct answer is choiceC. Respiratory rate.
Choice A rationale:
Monitoring the fetal heart rate (FHR) is crucial during labor to assess the well-being of the fetus.However, when administering magnesium sulfate, the primary concern is the mother’s respiratory status due to the risk of respiratory depression, which can be a side effect of the medication.
Choice B rationale:
While bowel sounds are an important part of a comprehensive assessment, they are not the primary concern when administering magnesium sulfate.Magnesium sulfate primarily affects the neuromuscular and respiratory systems.
Choice C rationale:
Respiratory rate is the primary nursing assessment for a client receiving magnesium sulfate IV.Magnesium sulfate can cause respiratory depression, so it is essential to monitor the client’s respiratory status closely to detect any signs of respiratory compromise early.
Choice D rationale:
Monitoring temperature is important in any clinical setting, but it is not the primary concern when administering magnesium sulfate.The primary focus should be on the respiratory rate due to the potential for respiratory depression.
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