A nurse in a prenatal clinic is caring for a client who reports that her menstrual period is 2 weeks late. The client appears anxious and asks the nurse if she is pregnant. Which of the following responses should the nurse make?
"You can miss your period for several other reasons. Describe your typical menstrual cycle
"If you have been sexually active and haven't used protection it is likely that you are pregnant
"Let's check to see if you have any other signs of pregnancy. Have you noticed any abdominal enlargement yet?
"Because you have missed your period, you should try taking a home pregnancy test before you start worrying
The Correct Answer is A
Choice A Reason:
"You can miss your period for several other reasons. Describe your typical menstrual cycle." This response acknowledges that a missed period can result from various factors other than pregnancy, such as stress, changes in weight, hormonal fluctuations, or certain medical conditions. Understanding the client's typical menstrual cycle can help the nurse gather more information about potential reasons for the late period.
Choice B Reason:
"If you have been sexually active and haven't used protection, it is likely that you are pregnant. “This response assumes pregnancy without exploring other possibilities or the client's individual situation.
Choice C Reason:
"Let's check to see if you have any other signs of pregnancy. Have you noticed any abdominal enlargement yet?" While considering other signs of pregnancy is reasonable, focusing on abdominal enlargement may not be the most accurate early indicator, and it's essential to explore a broader range of symptoms.
Choice D Reason:
"Because you have missed your period, you should try taking a home pregnancy test before you start worrying. "While suggesting a home pregnancy test is reasonable, it may be more beneficial to gather additional information about the client's menstrual cycle and potential symptoms before jumping directly to a test.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Fetal lie being longitudinal is a normal and common fetal lie. It refers to the long axis of the fetus being parallel to the long axis of the mother.
B. Fetal position being persistent occiput posterior is a potential contributing cause.
Occiput posterior position (OP) can result in a more challenging and prolonged labor. This position, where the back of the baby's head is facing the mother's spine, is associated with increased back pain during labor.
C. Fetal attitude in general flexion is a favorable presentation for labor. Flexion allows for a smaller presenting diameter of the fetal head, facilitating descent through the birth canal.
D. Maternal pelvis being gynecoid is a favorable pelvic type for childbirth. The gynecoid pelvis is typically associated with easier labor and delivery.
Correct Answer is C
Explanation
Choice A Reason:
Left upper quadrant is incorrect. The left upper quadrant is less likely to be the area where the point of maximum intensity of the fetal heart is heard when the fetal position is left occipital anterior.
Choice B Reason:
Right upper quadrant is incorrect. The right upper quadrant is not the typical location for assessing fetal heart tones when the fetal position is left occipital anterior. The heart tones are generally heard more towards the left side.
Choice C Reason:
Left lower quadrant is correct. Placing the ultrasound transducer in the left lower quadrant is likely to provide the best detection of the fetal heart tones in the described fetal position.
Choice D Reason:
Right lower quadrant is incorrect. Similar to the right upper quadrant, the right lower quadrant is not the optimal location for assessing the fetal heart when the fetal position is left occipital anterior. The left side is typically where the point of maximum intensity is found.
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