A nurse in a prenatal clinic is caring for a client who states that she might be pregnant because she feels the baby moving. How does the nurse classify this statement by the client?

"This is a presumptive sign of pregnancy."

"This is a positive sign of pregnancy."

"This is a probable sign of pregnancy."

"This is a potential sign of pregnancy."

Answer and Explanation

The Correct Answer is A

A: Quickening, which refers to the sensation of the baby moving in the womb, is considered a presumptive sign of pregnancy. It is called "presumptive" because it is subjective and can be attributed to other causes, such as gas or gastrointestinal movements.

B: Positive signs of pregnancy are those that are attributed only to the presence of a fetus, such as fetal heartbeat or visualization on ultrasound. Feeling the baby move (quickening) is not specific enough to confirm pregnancy on its own.

C: Probable signs of pregnancy are more objective and can be detected by a healthcare provider, such as a positive pregnancy test or ballottement (rebounding of the fetus against the examiner's fingers). Feeling the baby move is not a probable sign as it is subjective and can be attributed to other factors.

D: "Potential sign of pregnancy" is not a recognized classification in pregnancy signs.

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Correct Answer is C

Explanation

A) Administer oxygen using a nonrebreather mask: While oxygen may be necessary if there are signs of fetal distress, the priority action in this situation is to reposition the client and relieve potential cord compression.
B) Elevate the client's legs: Elevating the client's legs is not the most appropriate action in this situation and may not address the cause of the decelerations.
C) Place the client in the lateral position: This is the correct answer. The described pattern of the fetal heart rate (slowdown after the start of a contraction with the lowest rate occurring after the peak of the contraction) suggests late decelerations, which are often caused by uteroplacental
insufficiency or cord compression. Placing the client in the lateral position can help alleviate potential compression of the umbilical cord and improve fetal oxygenation.
D) Increase the rate of maintenance IV infusion: Increasing the IV infusion rate may not be the most appropriate action for late decelerations. Repositioning the client is the priority in this situation.

A. Fetal head compression B. Umbilical cord compression C. Uteroplacental insufficiency D. Maternal bradycardia

Correct Answer is C

Explanation

A) Fetal head compression: Fetal head compression would typically result in variable decelerations, not late decelerations.
B) Umbilical cord compression: Umbilical cord compression is associated with variable decelerations, not late decelerations.
C) Uteroplacental insufficiency: Late decelerations occur due to decreased blood flow and oxygen supply to the fetus, which can be caused by uteroplacental insufficiency. This condition can lead to fetal hypoxia during contractions.
D) Maternal bradycardia: Maternal bradycardia would not directly cause late decelerations in the fetal heart rate.

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A nurse in a prenatal clinic is caring for a client who states that she might be pregnant because she feels the baby moving. How does the nurse classify this statement by the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?

Correct Answer is C

Explanation

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