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."

Answer and Explanation

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.

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Correct Answer is C

Explanation

Explanation:

A. Women during labor and birth:

Maternity nursing does involve caring for women during labor and birth. Nurses in labor and delivery units provide support, monitoring, and assistance to women as they progress through labor and deliver their babies. This aspect of maternity nursing focuses specifically on the care of women during the active stages of childbirth, including pain management, labor progression, and ensuring a safe delivery experience.

B. Mothers and fathers during hospitalization for childbirth:

Maternity nursing also involves caring for both mothers and fathers during their hospitalization for childbirth. Nurses provide education, support, and assistance to new parents as they adjust to the postpartum period and learn to care for their newborns. This includes teaching about newborn care, breastfeeding support, postpartum recovery, and emotional support for the entire family unit.

C. Families during the childbearing process:

This choice is the most comprehensive and accurate description of the client focus in maternity nursing. Maternity nursing encompasses care for entire families during the entire childbearing process, from preconception to postpartum. This includes providing education, support, and guidance to expectant parents, assisting with childbirth, promoting bonding and attachment between parents and newborns, and addressing the physical and emotional needs of the family as they navigate the transitions of pregnancy, childbirth, and early parenthood.

D. Childbearing women during acute illness:

While maternity nursing does involve caring for childbearing women during periods of acute illness related to pregnancy or childbirth complications, this focus is more limited compared to the broader scope of caring for families throughout the entire childbearing process. Maternity nurses may be involved in managing complications such as preeclampsia, gestational diabetes, or postpartum hemorrhage, but their role extends beyond acute illness management to include comprehensive prenatal, intrapartum, and postpartum care for women and their families.

A. A client who is at 28 weeks of gestation and receiving terbutaline reports fine tremors B. A client who has a diagnosis of preeclampsia has 2+ proteinuria and 2+ patellar reflexes C. A client who has a diagnosis of preeclampsia reports epigastric pain and unresolved headache D. A tearful client who is at 32 weeks of gestation and is experiencing irregular, frequent contractions

Correct Answer is C

Explanation

Explanation:

A. A client who is at 28 weeks of gestation and receiving terbutaline reports fine tremors:

Fine tremors are a known side effect of terbutaline, which is often used to delay preterm labor by relaxing the uterus. While tremors are a common and expected side effect of terbutaline, they are not typically considered an urgent concern unless they are severe or accompanied by other concerning symptoms.

B. A client who has a diagnosis of preeclampsia has 2+ proteinuria and 2+ patellar reflexes:

Proteinuria (2+) and increased deep tendon reflexes (2+) are significant findings in a client with preeclampsia, indicating worsening of the condition and potential organ involvement. However, they may not require immediate reporting unless accompanied by other severe symptoms such as severe hypertension, severe headache, visual disturbances, or epigastric pain.

C. A client who has a diagnosis of preeclampsia reports epigastric pain and unresolved headache:

This is the correct answer. Epigastric pain and unresolved headache are concerning symptoms in a client with preeclampsia and can indicate worsening of the condition or complications such as HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count). These symptoms may suggest liver involvement, which is a serious complication of preeclampsia and requires immediate evaluation and management by the provider.

D. A tearful client who is at 32 weeks of gestation and is experiencing irregular, frequent contractions:

While tearfulness and irregular, frequent contractions may indicate emotional distress or early labor, they are not typically considered urgent findings unless accompanied by other signs of impending preterm labor such as cervical changes or regular, painful contractions. Immediate reporting is important if there are signs of active labor or cervical changes, but based on the information provided, this finding is not as urgent as the epigastric pain and unresolved headache in a client with preeclampsia.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse should recognize that which of the following statements most accurately describes the client focus of maternity nursing?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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