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. This test assesses fetal lung maturity.
The explanation provided is incorrect. The maternal serum alpha-fetoprotein (MSAFP) test is not used to assess fetal lung maturity. Fetal lung maturity is typically assessed through tests such as amniocentesis, which evaluates factors like the lecithin-to-sphingomyelin (L/S) ratio and phosphatidylglycerol (PG) levels in amniotic fluid.
B. This test identifies an Rh incompatibility between the mother and fetus.
The explanation provided is also incorrect. The MSAFP test is not used to identify Rh (Rhesus) incompatibility between the mother and fetus. Rh incompatibility is determined through other tests, such as blood typing (Rh factor) and antibody screening.
C. It assesses various markers of fetal well-being.
This explanation is not accurate. While the MSAFP test does provide information about certain fetal abnormalities, it is primarily used as a screening test for neural tube defects (spinal defects) and abdominal wall defects rather than assessing overall fetal well-being, which involves a comprehensive evaluation of various fetal parameters.
D. It is a screening test for spinal defects in the fetus.
This explanation is correct. The MSAFP test is indeed a screening test specifically used to assess the risk of spinal defects, also known as neural tube defects, in the fetus. These defects include conditions such as spina bifida. The test measures the levels of alpha-fetoprotein in the mother's blood to screen for these abnormalities during pregnancy.
Correct Answer is B
Explanation
Explanation:
A. The biparietal diameter
The biparietal diameter is a measurement of the fetal head's diameter, which is often assessed during routine prenatal ultrasounds to estimate gestational age and monitor fetal growth. However, in the scenario described, the client is experiencing heavy vaginal bleeding without contractions at 38 weeks of gestation. The focus is on the immediate concern of the fetus's well-being rather than assessing specific fetal measurements like the biparietal diameter.
B. Viability of the fetus
This choice is correct for the scenario described. Viability refers to the ability of the fetus to survive outside the uterus. Heavy vaginal bleeding near term raises concerns about potential harm to the fetus and its viability. An ultrasound would be performed to assess the fetal heart rate, movement, and overall condition to determine if the fetus is viable or if there are any immediate concerns that need to be addressed.
C. Fetal lung maturity
Fetal lung maturity is typically assessed closer to the end of pregnancy, usually around 36 to 39 weeks of gestation, to determine if the fetus's lungs are developed enough for birth. While important for planning deliveries, assessing fetal lung maturity is not the primary concern in a situation where the client is experiencing heavy vaginal bleeding without contractions at 38 weeks of gestation.
D. Location of the placenta
The location of the placenta is important for monitoring placental health and assessing potential complications such as placenta previa. However, in the context of heavy vaginal bleeding without contractions at 38 weeks of gestation, the immediate concern is the well-being and viability of the fetus rather than the placental location.
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