A nurse is teaching a client about positive signs of pregnancy.
Which of the following findings should the nurse include?
Fetal heart tones detected by ultrasound.
Breast tenderness.
Positive urine pregnancy test.
Fatigue.
The Correct Answer is A
The correct answer is choice A.
Choice A rationale:
Fetal heart tones detected by ultrasound are a positive sign of pregnancy because they provide direct evidence of a fetus.
Choice B rationale:
Breast tenderness is a presumptive sign of pregnancy, not a positive one, as it can be caused by other conditions such as premenstrual syndrome.
Choice C rationale:
A positive urine pregnancy test is a probable sign of pregnancy, not a positive one, as it measures the presence of hCG, a hormone produced during pregnancy. However, certain medications and medical conditions can also produce hCG.
Choice D rationale:
Fatigue is a presumptive sign of pregnancy, not a positive one, as it can be caused by various other conditions such as stress or illness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A.
Choice A rationale:
The GTPAL system stands for Gravida, Term, Preterm, Abortions, and Living children. In this case, the woman has been pregnant 4 times (Gravida 4), has had one term birth (Term 1), one preterm birth (Preterm 1), one abortion/miscarriage (Abortions 1), and one living child (Living 1). Therefore, the correct classification is 4, 1, 1, 1, 1.
Choice B rationale:
This choice incorrectly classifies the number of pregnancies (Gravida should be 4, not 3) and does not account for the preterm birth or the number of living children.
Choice C rationale:
This choice overcounts the number of term births and living children.
Choice D rationale:
This choice incorrectly classifies the number of pregnancies (Gravida should be 4, not 3) and overcounts the number of living children.
Correct Answer is D
Explanation
The correct answer is choice D.
Choice A rationale:
Rho (D) immunoglobulin is not administered when both the client and the newborn are Rh negative.
Choice B rationale:
Rho (D) immunoglobulin is not administered when both the client and the newborn are Rh positive.
Choice C rationale:
Rho (D) immunoglobulin is not administered when the client is Rh positive and the newborn is Rh negative.
Choice D rationale:
Rho (D) immunoglobulin is administered when the client is Rh negative and the newborn is Rh positive. Therefore, this choice is correct.
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