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A client asks the nurse what was meant when the physician told her she had a positive Chadwick’s sign. Which of the following information about the finding would be appropriate for the nurse to convey at this time?
- A. It is a purplish stretch mark on your abdomen.
- B. It means that you are having heart palpitations.
- C. It is a bluish coloration of your cervix and vagina.
- D. It means the doctor heard abnormal sounds when you breathed in.
Correct Answer: C
Rationale: Chadwick’s sign is a bluish coloration of the cervix and vagina due to increased blood flow, which is a common early sign of pregnancy.
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An antenatal client is informing the nurse of her prenatal signs and symptoms. Which of the following findings would the nurse determine are presumptive signs of pregnancy? Select all that apply.
- A. Amenorrhea.
- B. Breast tenderness.
- C. Quickening.
- D. Frequent urination.
Correct Answer: A
Rationale: Presumptive signs of pregnancy are subjective and include amenorrhea, breast tenderness, quickening, and frequent urination. Uterine growth is a probable sign of pregnancy.
The nurse is educating a pregnant patient who is at 36 weeks gestation about the signs of labor. Which statement by the patient indicates effective teaching?
- A. I should report regular contractions that occur every 5 minutes for 1 hour.
- B. I should avoid drinking fluids until my contractions stop.
- C. If I lose my mucous plug, I should go to the hospital immediately.
- D. I should stay home and rest as long as my contractions are not painful.
Correct Answer: A
Rationale: The correct answer is A because reporting regular contractions occurring every 5 minutes for 1 hour is a key sign of active labor. This pattern indicates the onset of true labor and the need to seek medical attention.
Explanation:
1. Regular contractions every 5 minutes indicate active labor is likely.
2. Sustained contractions for an hour suggest progression of labor.
3. Seeking medical advice is crucial for appropriate management.
Incorrect Choices:
B. Incorrect. Staying hydrated is important during labor to prevent dehydration.
C. Incorrect. Losing the mucous plug is a sign of early labor, not an emergency.
D. Incorrect. Painful contractions are not the sole indicator of active labor; regularity is key.
A nurse is assessing a laboring person for signs of uterine rupture. What is the most common sign of uterine rupture?
- A. abdominal pain
- B. vaginal bleeding
- C. decreased fetal movement
- D. increased fetal heart rate
Correct Answer: C
Rationale: The correct answer is C: decreased fetal movement. Uterine rupture can lead to decreased blood flow to the fetus, resulting in reduced fetal movement. This sign is crucial as it indicates fetal distress and the need for immediate medical intervention. Abdominal pain (A) can be present but is not specific to uterine rupture. Vaginal bleeding (B) is a sign of placental abruption, not uterine rupture. Increased fetal heart rate (D) can occur due to fetal distress, but decreased fetal movement is a more direct sign of uterine rupture.
Which finding would the nurse view as normal when evaluating the laboratory reports of a 34-week gestation client?
- A. Anemia.
- B. Thrombocytopenia.
- C. Polycythemia.
- D. Hyperbilirubinemia.
Correct Answer: A
Rationale: Anemia is relatively common in pregnancy due to increased blood volume and iron demands. Polycythemia, thrombocytopenia, and hyperbilirubinemia are not typical findings.
A pregnant patient reports experiencing dizziness and fainting when standing up quickly. What is the nurse's most appropriate response?
- A. Instruct the patient to avoid standing for long periods.
- B. Encourage the patient to increase sodium intake.
- C. Recommend that the patient take frequent naps during the day.
- D. Teach the patient to rise slowly from a sitting or lying position.
Correct Answer: D
Rationale: The correct answer is D: Teach the patient to rise slowly from a sitting or lying position. This response is appropriate because the patient is likely experiencing orthostatic hypotension, which is common during pregnancy due to hormonal changes. Rising slowly helps prevent sudden drops in blood pressure, reducing dizziness and fainting.
A: Instructing the patient to avoid standing for long periods does not address the underlying issue of orthostatic hypotension.
B: Encouraging increased sodium intake may not be necessary and could potentially have negative effects.
C: Recommending frequent naps does not address the immediate problem of orthostatic hypotension when standing up quickly.