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

Answer and Explanation

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.

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Correct Answer is ["415"]

Explanation

To calculate the amount of NG drainage, the nurse should subtract the amount of irrigation fluid from the amount of fluid in the NG canister. The irrigation fluid is not part of the drainage, but rather a way to keep the NG tube patent and prevent clogging.

The amount of irrigation fluid is 30 mL x 2 = 60 mL.

The amount of fluid in the NG canister is 475 mL.

Therefore, the amount of NG drainage is 475 mL - 60 mL = 415 mL.

The answer should be rounded to the nearest whole number and use a leading zero if it applies. Do not use a trailing zero.

Therefore, the final answer is 415 mL.

A. 24 hours before delivery and 24 hours after delivery B. In the first trimester and within 2 hours of delivery C. At 28 weeks gestation and again within 72 hours after delivery D. At 32 weeks gestation and immediately before discharge

Correct Answer is C

Explanation

Choice A Reason: This is incorrect because administering Rho(D) immune globulin 24 hours before delivery is too early and may not provide adequate protection for the fetus. Administering it 24 hours after delivery is too late and may not prevent the mother from developing antibodies against the fetal Rh-positive blood cells.

Choice B Reason: This is incorrect because administering Rho(D) immune globulin in the first trimester is unnecessary and may not be effective, as the risk of Rh isoimmunization is very low before 28 weeks of gestation. Administering it within 2 hours of delivery is appropriate, but not sufficient, as it should be repeated within 72 hours after delivery.

Choice C Reason: This is correct because administering Rho(D) immune globulin at 28 weeks gestation and again within 72 hours after delivery is the recommended schedule for preventing Rh isoimmunization in Rh-negative pregnant women who have Rh-positive partners. This regimen can prevent up to 99% of cases of Rh isoimmunization by blocking the maternal immune response to the fetal Rh-positive blood cells.

Choice D Reason: This is incorrect because administering Rho(D) immune globulin at 32 weeks gestation is too late and may not prevent Rh isoimmunization if there has been any fetal-maternal hemorrhage before that time. Administering it immediately before discharge is also too late and may not prevent the mother from developing antibodies against the fetal Rh-positive blood cells.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["415"]

Explanation

It is determined that a client's blood Rh is negative and her partner's is positive. To help prevent Rh isoimmunization, the nurse would expect to administer Rho(D) immune globulin at which time?

Correct Answer is C

Explanation

A client with hyperemesis gravidarum is admitted to the facility after being cared for at home without success. What would the nurse expect to include in the client's plan of care?

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During a vaginal exam, the nurse notes that the lower uterine segment is softened. The nurse documents this finding as:

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A client comes to the prenatal clinic for her first visit. When determining the client's estimated due date, the nurse understands that which method is the most accurate?