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 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 sexual contact.
- D. It is primarily transmitted through respiratory droplets.
Correct Answer: C
Rationale: HIV is primarily transmitted through sexual contact involving infected fluids like semen or vaginal secretions. Mosquitoes, respiratory droplets, and puncture wounds (rare) don't commonly spread HIV.
When assessing a woman in her first trimester, which emotional response would the nurse most likely expect to find?
- A. Ambivalence
- B. Emotional lability
- C. Introversion
- D. Acceptance
Correct Answer: B
Rationale: Emotional lability is typical in the first trimester from hormonal changes causing irritability or crying. Ambivalence is less common unless conflicted, introversion isn't pregnancy-specific, and acceptance grows over time.
A woman hospitalized with severe preeclampsia is being treated with hydralazine to control blood pressure. Which finding would lead the nurse to suspect that the client is having an adverse effect associated with this drug?
- A. Gastrointestinal bleeding
- B. Sweating
- C. Tachycardia
- D. Blurred vision
Correct Answer: C
Rationale: Hydralazine, a vasodilator, can cause reflex tachycardia as blood pressure drops, increasing cardiac strain. Gastrointestinal bleeding, sweating, and blurred vision (a preeclampsia symptom) are not typical adverse effects.
A client who is 4 months pregnant is at the prenatal clinic for her initial visit. Her history reveals she has 7-year-old twins who were born at 34 weeks gestation, a 2-year-old son born at 39 weeks gestation, and a spontaneous abortion 1 year ago at 6 weeks gestation. Using the GTPAL method, the nurse would document her obstetric history as:
- A. 3-2-1-0-3
- B. 4-1-1-1-3
- C. 4-2-1-3-1
- D. 3-1-2-2-3
Correct Answer: B
Rationale: GTPAL: Gravida (4 pregnancies: twins, son, abortion, current), Term (1 at 39 weeks), Preterm (1 at 34 weeks), Abortions (1 at 6 weeks), Living (3 children). Thus, 4-1-1-1-3 is correct. Other options miscalculate pregnancies, preterm births, or living children.
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.