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. "A gain of about 1 pound per week is the best pattern for you."

This response suggests a weight gain pattern rather than a total recommended weight gain for the entire pregnancy. A gain of about 1 pound per week would typically align with the recommended weight gain for individuals with a normal pre-pregnancy BMI (Body Mass Index). However, for someone with an overweight BMI (BMI 25 to 29.9), this rate of weight gain might be higher than the recommended range. Therefore, it may not be the best pattern for the client with a BMI of 26.5.

B. "It would be best if you gained about 11 to 20 pounds."

This response provides a weight gain range that is more appropriate for individuals with an obese BMI (BMI 30 or higher) rather than those with an overweight BMI. The recommended weight gain for someone with an overweight BMI is higher than 11 to 20 pounds. Therefore, this response underestimates the recommended weight gain for the client with a BMI of 26.5.

C. "The recommendation for you is about 15 to 25 pounds."

This response aligns with the recommended weight gain range for individuals with an overweight BMI (BMI 25 to 29.9). According to the Institute of Medicine (IOM) guidelines, the recommended weight gain for someone with an overweight BMI is about 15 to 25 pounds during pregnancy. This choice accurately reflects the appropriate recommendation for the client with a BMI of 26.5.

D. "A gain of about 25 to 35 pounds is recommended for you."

This response suggests a weight gain range that is more appropriate for individuals with a normal pre-pregnancy BMI (BMI 18.5 to 24.9). The recommended weight gain for someone with an overweight BMI is lower than 25 to 35 pounds. Therefore, this response overestimates the recommended weight gain for the client with a BMI of 26.5.

A. Evaluate neurologic status every 8 hr. B. Provide a dark, quiet environment. C. Administer magnesium sulfate IV. D. Ensure that calcium gluconate is readily available. E. Assess respiratory status every 4 hr.

Correct Answer is ["B","C","D"]

Explanation

Explanation:

A. Evaluate neurologic status every 8 hr.

While monitoring neurologic status is important in clients with severe gestational hypertension to assess for signs of impending eclampsia (seizures), more frequent monitoring is typically required, such as every 4 hours or even more frequently depending on the severity of the condition. Therefore, evaluating neurologic status every 8 hours is not sufficient for this client.

B. Provide a dark, quiet environment.

Creating a calm and low-stimulation environment helps to reduce the risk of seizures, which can be triggered by bright lights and loud noises in clients with severe gestational hypertension.

C. Administer magnesium sulfate IV.

Magnesium sulfate is commonly used to prevent seizures in clients with severe gestational hypertension (preeclampsia). It is a standard treatment to prevent eclampsia, a serious complication of preeclampsia characterized by seizures. Therefore, the nurse should expect to administer magnesium sulfate IV as part of the management plan for severe gestational hypertension.

D. Ensure that calcium gluconate is readily available.

Magnesium sulfate, while effective in preventing seizures, can lead to magnesium toxicity if levels become too high. Calcium gluconate is the antidote for magnesium sulfate toxicity. Therefore, the nurse should ensure that calcium gluconate is readily available to counteract any potential magnesium toxicity that may occur during magnesium sulfate administration.

E. Assess respiratory status every 4 hr.

Monitor and record vital signs (blood pressure, pulse, respirations, O2 saturation) every 1 hour x’s 8 hours after maintenance infusion is started and vital signs for bolus infusion are complete.If respiratory rate < 12 breaths/min, draw magnesium level, notify HCP, and observe closely.

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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

A nurse is caring for a client at the first prenatal visit who has a BMI of 26.5. The client asks how much weight she should gain during pregnancy. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

A nurse is admitting a client who is at 37 weeks of gestation and diagnosed with severe gestational hypertension. Which of the following actions should the nurse expect to implement? (Select all that apply.)

Correct Answer is ["B","C","D"]

Explanation

A nurse in the antepartum unit is caring for a client who is at 36 weeks of gestation and has pregnancy-induced hypertension. Suddenly, the client reports continuous abdominal pain and vaginal bleeding. The nurse should suspect which of the following complications?

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A nurse is providing teaching about nutrition to a client at her first prenatal visit. Which of the following statements by the nurse should be included in the teaching?

A nurse is teaching a client who is at 15 weeks of gestation and is to undergo an amniocentesis. The nurse should explain that the purpose of this test is to identify which of the following conditions? (Select all that apply.)

A nurse is caring for a client diagnosed with preeclampsia and is being treated with magnesium sulfate IV. The client's respiratory rate is 10/min and deep-tendon reflexes are absent. Which of the following actions should the nurse take?

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

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