A nurse is reviewing the different signs of pregnancy with a client who is in her first trimester. Which of the following symptoms should the nurse classify as a positive sign of pregnancy?

Fetal movement felt by provider

Positive pregnancy test

Hegar's sign

Breast tenderness and nausea

Answer and Explanation

The Correct Answer is A

A. Fetal movement felt by provider
This is correct because fetal movement confirmed by a healthcare provider is a positive sign of pregnancy, as it directly confirms fetal presence.

B. Positive pregnancy test
This is incorrect because a positive pregnancy test is a probable sign, not a positive sign. It detects hCG, which can also be produced in conditions like gestational trophoblastic disease (molar pregnancy).

C. Hegar’s sign
This is incorrect because Hegar’s sign (softening of the lower uterus) is a probable sign, not a positive sign, as it can occur due to other physiological changes.

D. Breast tenderness and nausea
This is incorrect because breast tenderness and nausea are presumptive signs of pregnancy, meaning they are subjective symptoms that could be caused by other conditions (e.g., PMS, stress, illness).

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Correct Answer is A

Explanation

A. The client's level of sexual stimulation
Sildenafil requires sexual stimulation to be effective. It enhances blood flow to the penis but does not automatically cause an erection. The client should be educated that adequate sexual arousal is necessary for the medication to work.

B. If taken with a high-fat meal, the medication is more effective
Taking sildenafil with a high-fat meal can actually delay its absorption and reduce effectiveness. Clients should be advised to take it on an empty stomach or with a light meal for optimal results.

C. The client's recent consumption of caffeine
Caffeine intake does not interfere with sildenafil’s effectiveness. However, excessive caffeine consumption may contribute to vasoconstriction, which could indirectly affect erectile function.

D. If client took an additional dose to achieve an erection
Taking an extra dose of sildenafil is not recommended and can increase the risk of serious side effects such as hypotension, priapism (prolonged erection), and cardiovascular complications. The client should follow prescribed dosing guidelines.

A. Negative for protein on a urine dipstick: B. Blood pressure of 150/96 mmHg C. Elevated ALT/AST D. Blood pressure of 162/112 mmHg E. Seizures

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"C"}}

Explanation

Preeclampsia:

Blood pressure of 150/96 mmHg: A BP of ≥140/90 mmHg on two occasions at least 4 hours apart after 20 weeks of gestation in a previously normotensive client is diagnostic of preeclampsia.

Preeclampsia with Severe Features:

Blood pressure of 162/112 mmHg: Severe hypertension is ≥160/110 mmHg on two occasions at least 4 hours apart. This is a criterion for severe preeclampsia, requiring immediate intervention to prevent complications like eclampsia or stroke.

Elevated liver enzymes (ALT/AST > 2x the upper limit of normal) are indicative of severe preeclampsia due to hepatic involvement. This can progress to HELLP syndrome, increasing the risk of liver rupture and disseminated intravascular coagulation (DIC).

Neither:

Negative for protein on a urine dipstick: Preeclampsia is typically diagnosed with proteinuria (≥300 mg in 24 hours or protein/creatinine ratio ≥0.3). A negative urine dipstick means proteinuria is absent, making preeclampsia unlikely. However, preeclampsia can also be diagnosed without proteinuria if other systemic features (e.g., thrombocytopenia, renal dysfunction) are present.

Seizures in a client with preeclampsia indicate eclampsia, which is a medical emergency requiring magnesium sulfate to prevent further seizures. If the client had no preeclampsia, the seizures could be due to another cause (e.g., epilepsy, metabolic disturbance).

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A nurse is reviewing the different signs of pregnancy with a client who is in her first trimester. Which of the following symptoms should the nurse classify as a positive sign of pregnancy?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A male client reports to the nurse that he took sildenafil for erectile dysfunction but did not achieve an erection. Which of the following considerations should the nurse evaluate to determine possible reasons for the lack of response?

Correct Answer is A

Explanation

G1P1, 37 weeks' gestation patient with a scheduled nonstress test (NST) As the nurse, you can identify whether the following findings are indicative of preeclampsia, preeclampsia with severe features, or neither. Select at least one answer in each row.

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"C"}}

Explanation

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