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 B
Explanation
The priority intervention for a newly-admitted client who has acute osteomyelitis is antibiotic therapy.
Choice A is incorrect because antipyretic therapy is not the priority intervention.
Choice C is incorrect because optimal nutrition and hydration are not the priority intervention.
Choice D is incorrect because surgical debridement of necrotic tissue is not the priority intervention.
Correct Answer is C
Explanation
The nurse should check for blood under the client’s buttocks.
A small amount of lochia rubra on the client’s perineal pad 4 hours postpartum is normal.
The fundus being midline and firm at the umbilicus is also a normal finding.
Choice A is incorrect because assisting the client to ambulate is not necessary at this time.
Choice B is incorrect because there is no need to increase the rate of IV fluids.
Choice D is incorrect because performing a fundal massage is not necessary since the fundus is already firm and midline.
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