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:
Evaluating the firmness of the uterus (fundus) is the first action the nurse should take when a client’s blood pressure drops postpartum. A soft or “boggy” uterus can indicate uterine atony, a leading cause of postpartum hemorrhage, which can lead to hypotension.
Choice B rationale:
Obtaining a type and crossmatch is important if the client needs a blood transfusion, but it is not the first action the nurse should take.
Choice C rationale:
Administering oxytocin infusion can help contract the uterus and control bleeding, but the nurse should first assess the uterus.
Choice D rationale:
Initiating oxygen therapy can help if the client is hypoxic, but the nurse should first assess the uterus.
Correct Answer is D
Explanation
The correct answer is choice D.
Choice A rationale:
While a urinary tract infection can cause frequent urination, it’s usually accompanied by other symptoms such as pain or burning during urination.
Choice B rationale:
Trauma to pelvic muscles can cause urinary incontinence, not necessarily increased frequency.
Choice C rationale:
Urinary overflow is a condition where the bladder is always full and can lead to frequent leakage of urine.
Choice D rationale:
Postpartum diuresis is the body’s way of getting rid of excess fluid accumulated during pregnancy, leading to increased urine production and frequency.
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