On the first prenatal visit, the woman's cervix feels softened upon examination. The nurse records this finding as: Select one:
Homans' sign.
Chadwick's sign.
Goodell's sign.
McDonald's sign.
The Correct Answer is C
Choice A Reason: Homans' sign. This is an incorrect answer that refers to a different sign that is not related to pregnancy. Homans' sign is a sign of deep vein thrombosis (DVT) that occurs when there is pain or discomfort in the calf or popliteal region when the foot is dorsiflexed. Homans' sign can be elicited by passive or active movement of the foot, but it is not a reliable or specific indicator of DVT.
Choice B Reason: Chadwick's sign. This is an incorrect answer that refers to a different sign of pregnancy that affects the color of the cervix, not the texture. Chadwick's sign is a sign of pregnancy that refers to the bluish or purplish discoloration of the cervix, vagina, and vulva due to increased blood flow and congestion. Chadwick's sign can be observed by visual inspection of the cervix during the first prenatal visit, usually around 6 to 8 weeks of gestation.
Choice C Reason: Goodell's sign. This is because Goodell's sign is a sign of pregnancy that refers to the softening of the cervix due to increased vascularity and edema. Goodell's sign can be detected by digital examination of the cervix during the first prenatal visit, usually around 6 to 8 weeks of gestation.
Choice D Reason: McDonald's sign. This is an incorrect answer that refers to a different sign of pregnancy that involves the angle of the uterus, not the cervix. McDonald's sign is a sign of pregnancy that refers to the ease of flexing the body of the uterus against the cervix, which creates an angle of 90 degrees or less. McDonald's sign can be assessed by bimanual examination of the uterus during the first prenatal visit, usually around 7 to 8 weeks of gestation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: Continuing to monitor and document fetal heart rate. This is an inadequate response that does not address the urgency of the situation or intervene to prevent fetal distress or demise.
Choice B Reason: Changing the mother's position to left lateral and giving oxygen by nasal cannula. This is a partial response that may improve maternal-fetal blood flow and oxygenation, but it does not resolve the cord compression or facilitate delivery.
Choice C Reason: With a sterile glove, maintaining pressure to lift the presenting part and emergently notifying the provider for a STAT C-section. This is an appropriate response that aims to reduce the cord compression by elevating the fetal head away from the cord and prepare for an immediate cesarean delivery.
Choice D Reason: Bolusing the patient with 1000cc lactated ringers. This is an irrelevant response that does not address the cause of the problem or improve fetal outcome.
Correct Answer is A
Explanation
Choice A Reason: Central cyanosis and poor tone. These are signs of hypoxia and asphyxia in newborns, which indicate a need for resuscitation. Central cyanosis means bluish discoloration of the skin or mucous membranes around the mouth, nose, or eyes. Poor tone means limpness or lack of muscle activity.
Choice B Reason: Heart rate of 160 beats per minute and spitting up mucus. These are not signs of hypoxia or asphyxia in newborns, but rather normal findings or minor issues. A normal heart rate for a newborn ranges from 120 to 160 beats per minute. Spitting up mucus may be due to excess secretions or swallowing amniotic fluid, which can be cleared by suctioning or burping.
Choice C Reason: Crying with respirations of greater than 60 breaths per minute. These are not signs of hypoxia or asphyxia in newborns, but rather normal or expected findings. Crying indicates that the newborn has a patent airway and adequate lung expansion. Respirations of greater than 60 breaths per minute may be normal for a newborn in transition or due to transient tachypnea, which usually resolves within a few hours.
Choice D Reason: Blue hands and feet but lips that are slowly pinking up. These are not signs of hypoxia or asphyxia in newborns, but rather a common condition called acrocyanosis. Acrocyanosis means bluish discoloration of the hands and feet due to poor peripheral circulation in response to cold exposure or stress. It does not affect oxygenation or ventilation and usually disappears within 24 to 48 hours after birth.
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