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 A

Explanation

Choice A: After an amniotomy (artificial rupture of membranes), the priority action by the nurse is to assess the fetal heart rate. Amniotomy can lead to changes in fetal heart rate patterns, and the nurse needs to ensure that the baby's wellbeing is not compromised after the procedure.

Choice B: Providing clean, dry underpads is important for maintaining hygiene and cleanliness after the procedure but is not the priority action. The fetal heart rate assessment takes precedence.

Choice C: Assessing the odor of the amniotic fluid is essential to identify any signs of infection, but it is not the priority action immediately following the amniotomy. Fetal wellbeing is the priority.

Choice D: Monitoring the client's temperature is important for identifying any signs of infection, but it is not the priority action. Assessing the fetal heart rate is more critical at this time.

A. "This always happens by the end of the first trimester of pregnancy." B. "This will occur during the last trimester of pregnancy." C. "This usually happens between the fourth and fifth months of pregnancy" D. "This will happen once the uterus begins to rise out of the pelvis."

Correct Answer is C

Explanation

A. "This always happens by the end of the first trimester of pregnancy.": Quickening typically occurs later in pregnancy, not by the end of the first trimester.
B. "This will occur during the last trimester of pregnancy.": Quickening occurs much earlier than the last trimester.
C. "This usually happens between the fourth and fifth months of pregnancy.": Quickening, which is the first perception of fetal movements by the mother, generally occurs between 16 to 20 weeks of gestation.
D. "This will happen once the uterus begins to rise out of the pelvis.": Quickening does not directly correlate with the rising of the uterus out of the pelvis.

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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 assists the provider who performs an amniotomy. Which of the following is the priority action by the nurse following the procedure?

Correct Answer is A

Explanation

A nurse is caring for a client who is at 6 weeks of gestation with her first pregnancy and asks the nurse when she can expect to experience quickening. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

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A nurse is teaching a group of clients who are in their first trimester about exercise during pregnancy. Which of the following statements should the nurse include in the teaching?

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A nurse is caring for a client who is in active labor when the client's membranes rupture. The fetal monitor tracing shows late decelerations. Which of the following actions should the nurse take first?

A nurse in a prenatal clinic is caring for a client who is at 39 weeks of gestation and who asks about the signs that precede the onset of labor. Which of the following should the nurse identify as a sign that precedes labor?

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