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A nurse is completing a health history and assessment for a client who reports they are pregnant.
Which of the following findings is a presumptive sign of pregnancy?

A.

Positive pregnancy test.

B.

Amenorrhea.

C.

Fetal heart sounds.

D.

Chadwick's sign.

Answer and Explanation

The Correct Answer is B

Choice A rationale

A positive pregnancy test is a probable sign of pregnancy as it indicates the presence of hCG, a hormone produced during pregnancy. However, it is not a presumptive sign, as other

conditions can also result in elevated hCG levels.

 

Choice B rationale

Amenorrhea, or the absence of menstrual periods, is a presumptive sign of pregnancy. It is one of the earliest indications that a woman may be pregnant, though it can also be

caused by other factors such as stress or hormonal imbalances.

 

Choice C rationale

Fetal heart sounds detected by Doppler ultrasound are a positive sign of pregnancy, confirming the presence of a fetus. This is not a presumptive sign as it is direct evidence of

pregnancy.

 

Choice D rationale

Chadwick's sign, a bluish discoloration of the cervix, vagina, and labia due to increased blood flow, is considered a probable sign of pregnancy. It is not a presumptive sign but rather

a physical change that occurs during pregnancy. .


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View Related questions

Correct Answer is D

Explanation

Choice A rationale

Instituting droplet precautions is not necessary for herpes simplex virus (HSV). HSV is primarily transmitted through direct contact with infected body fluids or lesions, not through respiratory droplets.

Choice B rationale

Administering ceftriaxone sodium is not appropriate for HSV. Ceftriaxone is an antibiotic used to treat bacterial infections, whereas HSV is a viral infection and requires antiviral treatment.

Choice C rationale

Informing the client they should bottlefeed the newborn is not necessary. Mothers with HSV can breastfeed as long as there are no herpetic lesions on the breast. Proper hand hygiene and preventive measures should be taken to avoid transmission.

Choice D rationale

Obtaining surface cultures from the newborn is the appropriate action. This helps in detecting the presence of HSV and initiating antiviral treatment if necessary. Early detection and treatment are crucial in preventing severe complications associated with neonatal HSV infection.

Correct Answer is B

Explanation

Choice A rationale

The fetal heartbeat is typically detectable by Doppler around 10-12 weeks, not as early as 6 weeks.

Choice B rationale

Monthly prenatal visits up to 28 weeks are standard practice for monitoring pregnancy.

Choice C rationale

A complete blood count is not performed at every prenatal visit but at specific intervals.

Choice D rationale

The blood test for neural tube defects, such as AFP, is usually done around 16-18 weeks, not 32 weeks.

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