Nokea
A woman comes to the prenatal clinic suspecting that she is pregnant, and assessment reveals probable signs of pregnancy. Which findings would the nurse most likely assess? Select all that apply.
- A. Ultrasound visualization of the fetus
- B. Softening of the cervix
- C. Positive pregnancy test
- D. Absence of menstruation
- E. Ballottement
- F. Auscultation of a fetal heart beat
Correct Answer: B,C,D,E
Rationale: Probable signs include softening of the cervix (Goodell's), positive pregnancy test (hCG), amenorrhea, and ballottement (fetal rebound). Ultrasound and fetal heartbeat are positive signs, confirming pregnancy definitively.
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A pregnant woman undergoes a triple/quadruple screen at 16 to 18 weeks' gestation. What would the nurse suspect if the woman's alpha-fetoprotein (AFP) level is decreased?
- A. Sickle-cell anemia
- B. Cardiac defects
- C. Down syndrome
- D. Respiratory disorders
Correct Answer: C
Rationale: Decreased AFP, with altered hCG and estriol, suggests Down syndrome (trisomy 21). Sickle-cell anemia, cardiac defects, and respiratory disorders don't typically lower AFP; cardiac defects may raise it.
A nurse is planning a presentation about HIV for a church-based group. Which of the following information about HIV transmission should the nurse include?
- A. It is primarily transmitted through mosquitoes.
- B. It is primarily transmitted through accidental puncture wounds.
- C. It is primarily transmitted through casual contact.
- D. It is primarily transmitted through direct contact with infected body fluids.
Correct Answer: D
Rationale: HIV spreads mainly through direct contact with infected fluids (blood, semen, vaginal fluid), like during sex or needle sharing. Mosquitoes, casual contact, and puncture wounds (rare) aren't primary modes.
Assessment of a pregnant woman reveals a pigmented line down the middle of her abdomen. The nurse documents this as which finding?
- A. striae gravidarum
- B. linea nigra
- C. vascular spiders
- D. melasma
Correct Answer: B
Rationale: Linea nigra is a dark line from umbilicus to pubis caused by increased melanin from hormonal changes. Striae gravidarum are stretch marks, vascular spiders are dilated vessels on face or chest, and melasma is facial pigmentation, none matching the abdominal line description.
Assessment of a pregnant woman and her fetus reveals tachycardia and hypertension. There is also evidence suggesting vasoconstriction. The nurse would question the woman about use of which substance?
- A. Marijuana
- B. Cocaine
- C. Nicotine
- D. Caffeine
Correct Answer: B
Rationale: Cocaine causes tachycardia, hypertension, and vasoconstriction, risking placental abruption and fetal distress. Marijuana causes relaxation, nicotine raises heart rate but vasodilates, and caffeine mildly stimulates but doesn't constrict vessels.
A nurse is teaching a pregnant client in her first trimester about discomforts that she may experience. The nurse determines that the teaching was successful when the woman identifies which discomforts as common during the first trimester? Select all that apply.
- A. Breast tenderness
- B. Urinary frequency
- C. Backache
- D. Cravings
- E. Leg cramps
Correct Answer: A,B,D
Rationale: First trimester discomforts include breast tenderness (hormonal growth), urinary frequency (bladder pressure), and cravings (taste changes). Backache and leg cramps typically occur later due to weight and nerve pressure.