A nurse is caring for a client who is in labor and tested positive for group B streptococcus B- hemolytic. Which of the following actions should the nurse take?

Choice A reason:

Breast changes are considered a presumptive sign of pregnancy. This means they are subjective indications reported by the woman and may not be definitive evidence of pregnancy. During pregnancy, the woman's breasts may undergo various changes such as tenderness, enlargement, and darkening of the areolas. These changes are primarily due to hormonal fluctuations and increased blood flow to the breast tissue.

Choice B reason:

Ballottement is not a presumptive sign of pregnancy. Ballottement is a clinical maneuver performed by a healthcare provider to assess the mobility of the fetus in the amniotic fluid. It involves tapping on the cervix and feeling for a rebound from the floating fetus. While it is an indication of pregnancy, it is not considered a presumptive sign as it requires a trained professional to detect.

Choice C reason:

Urinary frequency is a presumptive sign of pregnancy. During pregnancy, the growing uterus can put pressure on the bladder, leading to increased urinary frequency. However, urinary frequency can also be caused by other factors such as urinary tract infections, so it is not a definitive sign of pregnancy.

Choice D reason:

Nausea, specifically morning sickness, is a presumptive sign of pregnancy. Many pregnant women experience nausea and vomiting, especially during the first trimester, due to hormonal changes. However, nausea can also be caused by various other conditions, making it a presumptive rather than a confirmatory sign of pregnancy.

Choice E:

A positive pregnancy test is a probable sign of pregnancy rather than a presumptive sign. Pregnancy tests detect the presence of human chorionic gonadotropin (hCG), a hormone produced during pregnancy. A positive test provides strong evidence of pregnancy, but it is not considered a presumptive sign as it is an objective finding rather than a subjective symptom reported by the woman.

The nurse should maintain continuous observation of the adolescent.

Choice A reason:

The first and most crucial action when a patient expresses an intention to self-harm is to ensure their safety. By maintaining continuous observation, the nurse can closely monitor the adolescent's behavior and intervene promptly if any signs of self-harm emerge. This action helps prevent immediate harm and allows for timely interventions.

Choice B reason:

Applying wrist restraints to the adolescent (Choice B) would not be appropriate in this situation. Restraints are typically used as a last resort for patients who pose a danger to themselves or others and only when less restrictive measures have failed. In the case of self- harm, using restraints can increase the patient's distress and potentially worsen the situation.

Choice C reason:

Collecting data about the adolescent's mental status (Choice C) is an essential step in understanding their overall condition, but it should not be the first action taken. While gathering data is important for a comprehensive assessment, immediate safety concerns must take precedence.

Choice D reason:

Obtaining consent from the adolescent's guardian for the application of restraints (Choice D) is not the first priority when the patient expresses an intention to self-harm. The focus should be on ensuring the patient's immediate safety, and consent for restraints may be necessary only if other interventions prove inadequate.