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 A
Explanation
Choice A Reason: Trisomy numeric abnormality. Down syndrome is a genetic disorder that occurs when a person has three copies of chromosome 21 instead of two. This extra chromosome causes various physical and mental features that vary from person to person. Down syndrome is also called trisomy 21 because it involves three copies of chromosome 21.
Choice B Reason: Multifactorial inheritance is incorrect because it refers to a type of genetic disorder that results from the interaction of multiple genes and environmental factors. Examples of multifactorial disorders include cleft lip or palate, neural tube defects, diabetes, hypertension, and some types of cancer.
Choice C Reason: X-linked recessive inheritance is incorrect because it refers to a type of genetic disorder that affects males more than females because it is caused by a mutation on the X chromosome. Females have two X chromosomes, so they can be carriers or affected depending on whether they inherit one or two copies of the mutated gene. Males have one X chromosome and one Y chromosome, so they are always affected if they inherit the mutated gene from their mother. Examples of X-linked recessive disorders include hemophilia, color blindness, and Duchenne muscular dystrophy.
Choice D Reason: Chromosomal deletion is incorrect because it refers to a type of genetic disorder that occurs when a part of a chromosome is missing or deleted. This can cause various physical and mental problems depending on the size and location of the deletion. Examples of chromosomal deletion
Correct Answer is D
Explanation
Choice A: 28 weeks' gestation is too early to screen for group B streptococcus infection. Group B streptococcus (GBS) is a type of bacteria that can cause serious infections in newborns if transmitted from the mother during labor and delivery. The optimal time to screen for GBS is between 35 and 37 weeks' gestation.
Choice B: 32 weeks' gestation is also too early to screen for GBS infection. Screening at this time may not reflect the true colonization status of the mother at the time of delivery, as GBS can be transient or intermittent.
Choice C: 16 weeks' gestation is much too early to screen for GBS infection. Screening at this time has no clinical value, as GBS colonization can change throughout pregnancy.
Choice D: 36 weeks' gestation is the appropriate time to screen for GBS infection. Screening at this time can identify mothers who are colonized with GBS and who need intrapartum antibiotic prophylaxis to prevent neonatal sepsis, pneumonia, and meningitis.
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