A nurse is assessing a client who may be pregnant. The nurse reviews the client's history for presumptive signs. Which signs would the nurse most likely note? Select all that apply.
Nausea
Abdominal enlargement
Positive pregnancy test
Braxton Hicks contractions
Amenorrhea
Correct Answer : A,B,C,E
Choice A Reason: Nausea is a common presumptive sign of pregnancy, especially in the first trimester. It is caused by hormonal changes and may be accompanied by vomiting.
Choice B Reason: Abdominal enlargement is another presumptive sign of pregnancy, as the uterus grows to accommodate the developing fetus. It may be noticeable as early as 12 weeks of gestation.
Choice C Reason: A positive pregnancy test is a presumptive sign of pregnancy, as it detects the presence of human chorionic gonadotropin (hCG), a hormone produced by the placenta. However, it is not a definitive sign, as it may be affected by other factors such as medications, tumors, or false positives.
Choice D Reason: Braxton Hicks contractions are not a presumptive sign of pregnancy, but a probable sign. They are irregular and painless contractions of the uterus that occur throughout pregnancy, but become more frequent and noticeable in the third trimester. They are also known as false labor contractions.
Choice E Reason: Amenorrhea, or the absence of menstrual periods, is a presumptive sign of pregnancy, as it indicates that ovulation has ceased. However, it is not a definitive sign, as it may be caused by other factors such as stress, illness, or hormonal imbalances.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["31"]
Explanation
The correct answer is 31 gtts/min. To calculate the infusion rate, the nurse should use the following formula:
Infusion rate (gtts/min) = Volume (mL) x Drop factor (gtts/mL) / Time (min)
Plugging in the given values, we get:
Infusion rate (gtts/min) = 1000 mL x 15 gtts/mL / 480 min
Infusion rate (gtts/min) = 31.25 gtts/min
Rounding to the nearest whole number, we get 31 gtts/min.
Correct Answer is C
Explanation
Choice A Reason: This is incorrect because sickle-cell anemia is a genetic disorder that affects the shape and function of the red blood cells. It is not related to the AFP level, which is a protein produced by the fetal liver and yolk sac.
Choice B Reason: This is incorrect because cardiac defects are abnormalities in the structure or function of the heart. They are not related to the AFP level, which is a marker of neural tube defects and abdominal wall defects.
Choice C Reason: This is correct because Down syndrome is a chromosomal disorder that results from an extra copy of chromosome 21. It is associated with a decreased AFP level, as well as increased levels of human chorionic gonadotropin (hCG) and unconjugated estriol (uE3).
Choice D Reason: This is incorrect because respiratory disorders are problems that affect the lungs and breathing. They are not related to the AFP level, which reflects the fetal development and integrity.
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