A nurse is caring for a female client who suspects she is pregnant.
Which question, if asked by the nurse, is consistent with signs of early pregnancy?
“Have you had any shortness of breath?”.
“Have you had any episodes of loss of consciousness?”.
“Have you had any spotting?”.
“Have you noticed any tenderness in your breasts?”.
The Correct Answer is D
The correct answer is choice D. “Have you noticed any tenderness in your breasts?”
Breast tenderness is one of the early signs of pregnancy that may occur as early as one to two weeks after conception. It is caused by hormonal changes that prepare the breasts for lactation.
Choice A is wrong because shortness of breath is not a sign of early pregnancy. It may occur later in pregnancy due to the growing uterus pressing on the diaphragm.
Choice B is wrong because episodes of loss of consciousness are not a sign of early pregnancy. They may indicate a serious condition such as anemia, dehydration, or hypoglycemia that requires medical attention.
Choice C is wrong because spotting is not a sign of early pregnancy.
It may be a sign of implantation bleeding, which occurs when the fertilized egg attaches to the lining of the uterus. However, implantation bleeding is usually much lighter and shorter than a normal period.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D. The fluid that the mother has in her breasts before the milk comes in is called colostrum, which is rich in antibodies and nutrients that the baby needs.
It also helps to prevent jaundice by stimulating the baby’s bowel movements.
Therefore, the nurse should encourage the mother to breastfeed as soon as possible after birth and explain the benefits of colostrum.
Choice A is wrong because it discourages breastfeeding and may interfere with milk production and bonding.
Choice B is wrong because it implies that breastfeeding is only a skill and not a natural process that benefits both the mother and the baby.
Choice C is wrong because it focuses on the emotional aspect of breastfeeding and not the physiological one.
While breastfeeding may enhance the closeness between the mother and the baby, it is not the only reason to breastfeed.
Correct Answer is D
Explanation
The correct answer is choice D. Apply petrolatum to the patient’s perineum.This is because petrolatum can help soothe and protect the perineal area, which may be swollen, bruised, or have stitches after a vaginal delivery.Applying petrolatum can also prevent the pad from sticking to the wound and causing more pain.
Choice A is wrong because observing the patient for vaginal discharge of bright red blood is not a specific action for perineal care.Bright red blood may indicate postpartum hemorrhage, which requires immediate medical attention.
Choice B is wrong because assessing the patient’s vaginal tone is not a priority action for perineal care.Vaginal tone may be reduced after childbirth due to stretching of the pelvic floor muscles, but this can improve with time and exercises.
Choice C is wrong because massaging the patient’s perineum is not recommended for perineal care.Massaging the perineum may cause more trauma and discomfort to the area, especially if there are stitches or hemorrhoids.Massaging the fundus (the top of the uterus) may be done to help it contract and prevent bleeding, but this is different from massaging the perineum.
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