The nurse is conducting an annual examination on a young female who reports her last menses was 2 months ago.
Although the client insists she is not pregnant due to a negative home pregnancy test, which assessment should the nurse prioritize to assess for a possible pregnancy?
A positive urine hCG.
Uterine size and shape changes.
A fetal heartbeat.
Chadwick's sign.
The Correct Answer is A
A positive urine hCG test is a priority assessment to assess for a possible pregnancy.
The human chorionic gonadotropin (hCG) hormone is produced by the placenta after implantation and can be detected in the urine of pregnant women.
A urine hCG test is a common method used to confirm pregnancy.
Choice B is not an answer because changes in uterine size and shape occur later in pregnancy and are not a priority assessment for early pregnancy detection.
Choice C is not an answer because a fetal heartbeat can usually be detected at around 6-7 weeks of pregnancy and is not a priority assessment for early pregnancy detection.
Choice D is not an answer because Chadwick’s sign, which refers to the bluish discoloration of the cervix, vagina, and vulva due to increased blood flow, occurs later in pregnancy and is not a priority assessment for early pregnancy detection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A nurse caring for a toddler who had a cast applied 2 hours ago due to multiple fractures of the right hand should report immediately to the charge nurse if the fingers on the right hand have a capillary refill of 4 seconds.
This could indicate that there is a problem with circulation.
Choice A is not an answer because it is not unusual for a child to not attempt to move her right arm or fingers after having a cast applied.
Choice B is not an answer because it is not unusual for the fingertips of the right hand to be swollen and bruised after having a cast applied.
Choice D is not an answer because it is not unusual for a child to not keep their arm elevated on a pillow after having a cast applied.
Correct Answer is D
Explanation
“You should place your baby on her back when sleeping to decrease the risk of SIDS.” According to Mayo Clinic, placing a baby on their back to sleep is one of the most important measures that can be taken to help protect a child from SIDS1.
Choice A is incorrect because there is no evidence that SIDS is directly correlated to diphtheria, tetanus, and pertussis vaccines.
Choice B is incorrect because SIDS rates have actually decreased dramatically since the American Academy of Pediatrics issued its safe sleep recommendations in 19922.
Choice C is incorrect because while sleep apnea may contribute to breathing problems, it is not considered the main cause of SIDS1.
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