Nokea
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.
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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.
A woman's obstetric history indicates that she is pregnant for the fourth time and all of her children from previous pregnancies are living. One was born at 39 weeks of gestation, twins were born at 34 weeks of gestation, and another child was born at 35 weeks of gestation. What is her gravidity and parity using the GTPAL system?
- A. 3-1-1-1-3
- B. 4-1-2-0-4
- C. 3-0-3-0-3
- D. 4-2-1-0-3
Correct Answer: B
Rationale: The correct calculation of this woman's gravidity and parity is 4-1-2-0-4. The numbers reflect the woman's gravidity and parity information.
Some pregnant patients may complain of changes in their voice and impaired hearing. The nurse can tell these patients that these are common reactions to:
- A. a decreased estrogen level.
- B. displacement of the diaphragm, resulting in thoracic breathing.
- C. congestion and swelling, which occur because the upper respiratory tract has become more vascular.
- D. increased blood volume.
Correct Answer: C
Rationale: Estrogen levels increase, causing the upper respiratory tract to become more vascular producing swelling and congestion in the nose and ears leading to voice changes and impaired hearing.
The nurse admitting a 3-year-old patient with the medical diagnosis of pneumonia identifies congestion and inspiratory wheezes in both lungs. This information is considered part of which step of the nursing process?
- A. Diagnosis
- B. Evaluation
- C. Assessment
- D. Implementation
Correct Answer: C
Rationale: Identifying symptoms such as congestion and wheezing is part of the assessment phase of the nursing process, where data is collected and analyzed.
To reassure and educate pregnant patients about changes in their cardiovascular system, maternity nurses should be aware that:
- A. a pregnant woman experiencing disturbed cardiac rhythm, such as sinus arrhythmia requires close medical and obstetric observation, no matter how healthy she otherwise may appear.
- B. changes in heart size and position and increases in blood volume create auditory changes from 20 weeks to term.
- C. palpitations are twice as likely to occur in twin gestations.
- D. all of the above changes will likely occur.
Correct Answer: B
Rationale: Auscultatory changes should be discernible after 20 weeks of gestation.