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 B

Explanation

Choice A: Elevating the client's legs is a measure to increase blood flow to the brain in cases of orthostatic hypotension but may not be sufficient to improve fetal oxygenation in this situation. The lateral position is preferred as it improves uterine perfusion.

Choice B: The client's blood pressure of 80/40 mm Hg indicates hypotension, which can be a common side effect of epidural anesthesia. The priority nursing action is to place the client in a lateral (sidelying) position to improve blood flow to vital organs, including the uterus and placenta, and prevent further compromise of fetal oxygenation.

Choice C: Monitoring vital signs every 5 minutes is an important nursing action, but the priority in this situation is to address the hypotension and improve maternal and fetal wellbeing first.

Choice D: Notifying the provider is an important step, but it should not be the first action. Immediate intervention to address the hypotension is required to improve fetal oxygenation.

A. Reposition the client with one hip elevated or on her left side. B. Notify the provider of the findings. C. Ask the client if she needs pain medication. D. Have the client empty her bladder.

Correct Answer is A

Explanation

A) Reposition the client with one hip elevated or on her left side: This is the correct first priority action. The client's vital signs indicate hypotension (low blood pressure), which may be caused by supine hypotensive syndrome. This condition occurs when the pregnant uterus compresses the vena cava, reducing blood return to the heart and causing a drop in blood pressure. Repositioning the client on her left side or elevating one hip can relieve the pressure on the vena cava and
improve blood flow to both the mother and the baby.

B) Notify the provider of the findings: While it is essential to inform the provider about the client's status, the first priority is to address the potential cause of hypotension and maternal discomfort.

C) Ask the client if she needs pain medication: Pain management is essential, but the client's vital signs and potential hypotensive condition take precedence as the first priority.
D) Have the client empty her bladder: Emptying the bladder can help reduce pressure on the vena cava and may improve blood flow, but it is not the first priority action in this situation. Repositioning the client is the initial priority to relieve supine hypotensive syndrome.

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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

A nurse is caring for a client who is in labor and has an epidural anesthesia block. The client's blood pressure is 80/40 mm Hg, and the fetal heart rate is 140/min. Which of the following is the priority nursing action?

Correct Answer is B

Explanation

Correct Answer is A

Explanation

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