Nokea
A patient reports to the clinic nurse that she has not had a period in over 12 weeks, she is
- A. The patient's urine test is positive for hCG. What is the correct nursing action related to this information?
- B. Ask the patient if she has had any nausea or vomiting in the morning.
- C. Schedule the patient to be seen by a health care provider within the next 4 weeks.
- D. Send the patient to the maternity screening area of the clinic for a routine
Correct Answer: C
Rationale: The correct answer is C because scheduling the patient to be seen by a healthcare provider within the next 4 weeks is important for further evaluation and management of the patient's amenorrhea. This timeline allows for timely assessment and potential interventions if needed.
Choice A is incorrect as simply having a positive urine hCG test does not provide enough information on its own to determine the appropriate nursing action.
Choice B is incorrect as asking about nausea or vomiting does not address the need for a comprehensive assessment and evaluation of the patient's amenorrhea.
Choice D is incorrect as sending the patient to the maternity screening area assumes a pregnancy-related issue without proper evaluation and could lead to unnecessary testing or interventions.
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The nurse teaches a pregnant woman about the presumptive, probable, and positive signs of pregnancy. The woman demonstrates understanding of the nurse's instructions if she states that a positive sign of pregnancy is:
- A. a positive pregnancy test.
- B. fetal movement palpated by the nurse-midwife.
- C. Braxton Hicks contractions.
- D. quickening.
Correct Answer: B
Rationale: Positive signs of pregnancy are attributed to the presence of a fetus, such as hearing the fetal heartbeat or palpating fetal movement.
A woman at 10 weeks of gestation who is seen in the prenatal clinic with presumptive signs and symptoms of pregnancy likely will have:
- A. amenorrhea
- B. positive pregnancy test
- C. Chadwick's sign
- D. Hegar's sign
Correct Answer: A
Rationale: Presumptive signs of pregnancy include amenorrhea, nausea, and breast changes. Positive pregnancy tests and physical signs like Chadwick's or Hegar's signs are classified as probable signs.
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: Anticonvulsants may cause false-positive pregnancy test results.
To reassure and educate pregnant patients about changes in their breasts, nurses should be aware that:
- A. the visibility of blood vessels that form an intertwining blue network indicates full function of Montgomery's tubercles and possibly infection of the tubercles
- B. the mammary glands do not develop until 2 weeks before labor
- C. lactation is inhibited until the estrogen level declines after birth
- D. colostrum is the yellowish oily substance used to lubricate the nipples for breastfeeding
Correct Answer: C
Rationale: Lactation is inhibited during pregnancy due to high estrogen levels, which decline after birth, allowing lactation to begin. Colostrum is a nutrient-rich premilk fluid.
To reassure and educate pregnant patients about changes in the uterus, nurses should be aware that:
- A. lightening occurs near the end of the second trimester as the uterus rises into a different position.
- B. the woman's increased urinary frequency in the first trimester is the result of exaggerated uterine anteflexion caused by softening.
- C. Braxton Hicks contractions become more painful in the third trimester,
particularly if the woman tries to exercise - D. the uterine souffle is the movement of the fetus.
Correct Answer: B
Rationale: The correct answer is B. Increased urinary frequency in the first trimester is due to exaggerated uterine anteflexion caused by softening. This is because the growing uterus exerts pressure on the bladder, leading to the need for more frequent urination. This is a common physiological change in early pregnancy due to the hormonal effects on the pelvic floor muscles and bladder capacity.
A: Lightening typically occurs near the end of the third trimester, not the second trimester, as the baby drops lower into the pelvis in preparation for birth.
C: Braxton Hicks contractions are typically painless and irregular in the third trimester, not more painful. Pain with exercise could indicate preterm labor.
D: Uterine souffle refers to the sound of blood flow through the uterine arteries, not movement of the fetus.