A nurse is collecting data from a client who is at 16 weeks of gestation and tells the nurse that she felt light fluttering in her stomach the prior day.
The nurse should use which of the following terms to document this finding?

Quickening.

Lightening.

Braxton Hicks contractions.

Chloasma.

Answer and Explanation

The Correct Answer is A

Choice A rationale:
Quickening is the term used to describe the first noticeable fetal movements felt by the pregnant person. It is often described as a fluttering or bubbling sensation in the lower abdomen.
Quickening typically occurs between 16 and 22 weeks of gestation, with an average of 18 weeks. It is a normal and reassuring sign that the pregnancy is progressing well.
The sensation of quickening is caused by the fetus moving its arms and legs, as well as by its body turning and rotating within the amniotic fluid.
It is important to note that not all pregnant women experience quickening at the same time, and some women may not feel it at all.
However, in this case, the client is at 16 weeks of gestation, which is within the typical timeframe for quickening to occur. Moreover, the client's description of "light fluttering in her stomach" is consistent with the sensation of quickening.

Choice B rationale:
Lightening is the term used to describe the descent of the fetus into the pelvis in preparation for labor.
It typically occurs in the last few weeks of pregnancy, and is often accompanied by a feeling of increased pressure in the pelvis and bladder.
The client in this question is only at 16 weeks of gestation, so it is too early for lightening to have occurred.

Choice C rationale:
Braxton Hicks contractions are irregular, painless contractions of the uterus that can occur throughout pregnancy.
They are often described as a tightening or hardening of the uterus, and they may come and go over a period of several hours. Braxton Hicks contractions are not a sign of labor, but they can sometimes be mistaken for it.
The client in this question did not describe any contractions, so Braxton Hicks contractions are not a likely explanation for her symptoms.

Choice D rationale:
Chloasma is a skin condition that is characterized by brown patches on the face.
It is also known as the "mask of pregnancy" because it is more common in pregnant women. Chloasma is caused by hormonal changes during pregnancy, and it typically fades after delivery.
The client in this question did not describe any skin changes, so chloasma is not a likely explanation for her symptoms

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Correct Answer is B

Explanation

Choice A:

While rupture of fetal membranes is a potential risk with placenta previa, it's not the primary reason to avoid a pelvic exam. If the membranes are already ruptured, a pelvic exam may be necessary to assess cervical dilation and fetal station.

However, in the absence of ruptured membranes, the risk of profound bleeding outweighs the benefits of a pelvic exam in women with placenta previa.

Choice C:

Preterm labor is a potential complication of placenta previa, but it's not directly caused by a pelvic exam. If preterm labor is suspected, a pelvic exam may be necessary to assess cervical dilation and fetal station.

However, in the absence of preterm labor signs, a pelvic exam is not routinely recommended in women with placenta previa due to the risk of bleeding.

Choice D:

Infection is a potential risk with any invasive procedure, including a pelvic exam. However, it's not a major concern in women with placenta previa compared to the risk of bleeding.

Proper sterile technique during the exam can significantly reduce the risk of infection.

Choice B:

Profound bleeding is the most significant risk associated with a pelvic exam in women with placenta previa. The placenta is located abnormally low in the uterus, covering or partially covering the cervix. Any manipulation of the cervix, such as during a pelvic exam, can disrupt the placenta's attachment and cause significant bleeding.

This bleeding can be life-threatening for both the mother and the fetus. Therefore, it's crucial to avoid pelvic exams in women with placenta previa unless there's a compelling clinical reason to perform one.

A. A pelvic exam is required if you want birth control pills B. Don't worry, I will stay in there with you for the exam C. All you need to do is relax during the exam D. Tell me more about your concerns

Correct Answer is D

Explanation

Rationale for Choice A:
A pelvic exam is required if you want birth control pills. This response is not therapeutic because it dismisses the client's feelings and does not address her concerns. It focuses on the policy or requirement rather than the client's emotional needs. It could make the client feel like her anxiety is not justified or that she has no choice in the matter.

Rationale for Choice B:
Don't worry, I will stay in there with you for the exam. While this response may be intended to provide reassurance, it does not fully address the client's underlying concerns. It offers a solution without first exploring the specific reasons for the client's anxiety. It could also make the client feel dependent on the nurse's presence for comfort, rather than empowering her to manage her own anxiety.

Rationale for Choice C:
All you need to do is relax during the exam. This response is not therapeutic because it minimizes the client's feelings and suggests that she can simply control her anxiety by relaxing. It does not acknowledge the validity of her concerns or provide any guidance on how to manage those concerns. It could make the client feel like her anxiety is her fault or that she is not coping well.

Rationale for Choice D:
Tell me more about your concerns. This is the most therapeutic response because it encourages the client to express her feelings and concerns openly. It validates the client's experience and demonstrates active listening and empathy. It provides an opportunity for the nurse to gather more information about the specific reasons for the client's anxiety and to tailor interventions accordingly. It also empowers the client by allowing her to share her thoughts and take control of the conversation.

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A nurse is collecting data from a client who is at 16 weeks of gestation and tells the nurse that she felt light fluttering in her stomach the prior day. The nurse should use which of the following terms to document this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who is at 37 weeks of gestation and has placenta previa. Which of the following risks is the primary reason the nurse should avoid performing a pelvic examination?

Correct Answer is B

Explanation

A nurse is caring for a female client scheduled to have a pelvic exam. The client tells the nurse, “I’m really nervous. I’ve never had a pelvic exam before.” Which of the following is an appropriate therapeutic response by the nurse?

Correct Answer is D

Explanation

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A nurse is collecting data from a client who is at 16 weeks of gestation and tells the nurse that she felt light fluttering in her stomach the prior day.
The nurse should use which of the following terms to document this finding?