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The nurse is teaching a pregnant patient about signs of possible pregnancy complications. Which should the nurse include in the teaching plan? (Select all that apply.)
- A. Report watery vaginal discharge
- B. Report puffiness of the face or around the eyes.
- C. Report any bloody show when you go into labor.
- D. Report visual disturbances, such as spots before the eyes.
Correct Answer: A
Rationale: The correct answer is A: Report watery vaginal discharge. This is important as it could indicate premature rupture of membranes, which can lead to infection or preterm labor. Puffiness of the face or around the eyes (B) could be a sign of preeclampsia, not just a pregnancy complication. Bloody show during labor (C) is a normal sign of labor progression. Visual disturbances like spots (D) are more commonly associated with conditions like preeclampsia rather than general pregnancy complications.
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A woman is at 14 weeks of gestation. The nurse would expect to palpate the fundus at which level?
- A. Not palpable above the symphysis at this time
- B. Slightly above the symphysis pubis
- C. At the level of the umbilicus
- D. Slightly above the umbilicus
Correct Answer: B
Rationale: In normal pregnancies, the uterus grows at a predictable rate. It may be palpated above the symphysis pubis sometime between the 12th and 14th weeks of pregnancy.
A woman is in her seventh month of pregnancy. She has been reporting nasal congestion and occasional epistaxis. The nurse suspects that:
- A. this is a normal respiratory change in pregnancy caused by elevated levels of estrogen.
- B. this is an abnormal cardiovascular change, and the nosebleeds are an ominous sign.
- C. the woman is a victim of domestic violence and is being hit in the face by her partner.
- D. the woman has been using cocaine intranasally.
Correct Answer: A
Rationale: Rationale:
A: Correct. Nasal congestion and epistaxis are common in pregnancy due to increased estrogen causing mucosal swelling and vasodilation.
B: Incorrect. Nosebleeds are not typically indicative of cardiovascular issues in pregnancy.
C: Incorrect. There is no evidence to suggest domestic violence based on the symptoms provided.
D: Incorrect. Cocaine use would have more severe implications beyond just nasal congestion and epistaxis in pregnancy.
A first-time mother at 18 weeks of gestation comes for her regularly scheduled prenatal visit. The patient tells the nurse that she is afraid that she is going into premature labor because she is beginning to have regular contractions. The nurse explains that this is the Braxton Hicks sign and teaches the patient that this type of contraction:
- A. is painless.
- B. increases with walking.
- C. causes cervical dilation.
- D. impedes oxygen flow to the fetus.
Correct Answer: A
Rationale: Uterine contractions can be felt through the abdominal wall soon after the fourth month of gestation. Braxton Hicks contractions are regular and painless and continue throughout the pregnancy.
The breast includes:
- A. The nipple
- B. The ovaries
- C. The testes
- D. The scrotum
Correct Answer: A
Rationale: The nipple is a key anatomical feature of the breast, involved in lactation and feeding.
A 31-year-old woman believes that she may be pregnant. She took an OTC pregnancy test 1 week ago after missing her period; the test was positive. During her assessment interview, the nurse enquires about the woman's last menstrual period and asks whether she is taking any medications. The woman states that she takes medicine for epilepsy. She has been under considerable stress lately at work and has not been sleeping well. She also has a history of irregular periods. Her physical examination does not indicate that she is pregnant. She has an ultrasound scan that reveals she is not pregnant. What is the most likely cause of the false-positive pregnancy test result?
- A. She took the pregnancy test too early
- B. She takes anticonvulsants
- C. She has a fibroid tumor
- D. She has been under considerable stress and has a hormone imbalance
Correct Answer: B
Rationale: Anticonvulsant medications can cause false-positive pregnancy test results by interfering with hormone assays.