A nurse in a prenatal clinic is caring for a client who believes that she might be pregnant because she feels the baby moving. Which of the following statements should the nurse make?
"This is a probable sign of pregnancy."
"This is a possible sign of pregnancy."
"This is a positive sign of pregnancy."
"This is a presumptive sign of pregnancy."
The Correct Answer is D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Explanation:
A. Drowsiness: Mild drowsiness is a common side effect of magnesium sulfate therapy and is not necessarily indicative of toxicity. However, severe drowsiness or lethargy can be a sign of magnesium toxicity and should be reported to the provider.
B. Facial flushing: Facial flushing is a common side effect of magnesium sulfate administration and is generally not a sign of toxicity. It is often accompanied by warmth and redness of the skin but is not considered a serious adverse reaction.
C. Nausea: Nausea is another common side effect of magnesium sulfate therapy and is usually mild and transient. It is not typically indicative of toxicity unless it is severe and persistent.
D. Respiratory depression: Respiratory depression is a critical sign of magnesium toxicity. Excessive levels of magnesium can affect neuromuscular function, leading to respiratory muscle weakness and depression. This can result in shallow or slowed breathing, decreased oxygenation, and potential respiratory failure. Respiratory depression is a serious complication that requires immediate intervention, and the nurse should report it to the provider promptly.
Correct Answer is A
Explanation
Explanation:
A. Insert a gloved hand into the vagina to relieve pressure on the cord: This is the correct action because a prolapsed umbilical cord can become compressed, leading to decreased blood flow to the fetus. By inserting a gloved hand into the vagina and lifting the presenting part off the cord, the nurse can relieve pressure and improve blood flow to the fetus until further interventions can be initiated.
B. Cover the cord with a sterile, moist saline dressing: While covering the cord with a sterile, moist saline dressing can help prevent drying and protect the cord, it is not the first action to take in the case of a prolapsed cord. The priority is to relieve pressure on the cord to ensure adequate blood flow to the fetus.
C. Place the client in knee-chest position: Placing the client in a knee-chest position can also help relieve pressure on the cord by using gravity to shift the presenting part away from the cord. However, this should be done after inserting a gloved hand into the vagina to relieve immediate pressure on the cord.
D. Prepare the client for an immediate birth: While preparing the client for an immediate birth may be necessary if the situation cannot be resolved quickly, the first step is to relieve pressure on the cord to prevent fetal compromise.
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