A client suspects she is pregnant. The nurse is discussing the probable signs of pregnancy with the client.
Which of the following findings should the nurse include?
Breast tenderness.
Fetal heart tones detected by ultrasound.
Fetal movement.
Positive urine pregnancy test.
Positive urine pregnancy test.
The Correct Answer is D
Choice A rationale
Breast tenderness is considered a presumptive sign of pregnancy, as it can result from hormonal changes, but it is not definitive enough to confirm pregnancy.
Choice B rationale
Fetal heart tones detected by ultrasound are a positive sign of pregnancy. However, it is not a probable sign as it is definitive evidence of an existing pregnancy.
Choice C rationale
Fetal movement, often felt later in pregnancy, is a positive sign. It indicates an existing pregnancy but is not used to initially diagnose pregnancy.
Choice D rationale
A positive urine pregnancy test is a probable sign of pregnancy. It detects the presence of hCG (human chorionic gonadotropin), a hormone produced during pregnancy, and is a widely used indicator of probable pregnancy. .
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is B
Explanation
Choice A rationale
Prophylactic treatment for cytomegalovirus during pregnancy isn't generally recommended. CMV detection should lead to close monitoring rather than prophylactic treatment, as
current treatments pose risks without guaranteed efficacy.
Choice B rationale
Avoiding cat litter is crucial during pregnancy to prevent toxoplasmosis infection, which can cause severe fetal harm, including hydrocephalus, mental disabilities, and seizures, by
transferring through contact with cat feces.
Choice C rationale
While avoiding crowded places can reduce general infection risks, it is not specifically associated with preventing TORCH infections. TORCH infections refer to a set of perinatal infections that pose particular risks to fetal health.
Choice D rationale
Rubella immunization should be done before pregnancy, not during, as live vaccines carry risks. A woman should confirm immunity before conception to protect against congenital rubella syndrome.
Correct Answer is D
Explanation
Choice A rationale
Blue coloring of the hands and feet in an 8-hour-old newborn (acrocyanosis) is a common, benign finding as the newborn’s circulatory system adjusts post-birth. It does not require immediate intervention.
Choice B rationale
Small raised pearly spots on the nose (milia) are harmless and common in newborns. They do not necessitate any intervention.
Choice C rationale
An apical heart rate of 140 bpm is within the normal range for newborns and does not require intervention.
Choice D rationale
Nasal flaring and grunting are signs of respiratory distress in a newborn. This condition demands immediate intervention to ensure the newborn’s airway is clear and breathing is adequately supported.