Nokea
On the basis of this finding, the nurse can assume that the client is at least how many months' pregnant?
- A. 5 months
- B. 6 months
- C. 7 months
- D. 8 months
Correct Answer: A
Rationale: Ballottement, the rebound of the fetus when the cervix is tapped, is typically detectable around 4-5 months, indicating at least 5 months' gestation.
You may also like to solve these questions
The nurse is conducting a physical assessment of the pregnant client. Which physiological cervical changes associated with pregnancy should the nurse expect to find? Select all that apply.
- A. Formation of mucus plug
- B. Chadwick’s sign
- C. Presence of colostrum
- D. Goodell’s sign
- E. Cullen’s sign
Correct Answer: A,B,D
Rationale: Cervical changes associated with pregnancy include the formation of the mucus plug. Endocervical glands secrete a thick, tenacious mucus, which accumulates and thickens to form the mucus plug that seals the endocervical canal and prevents the ascent of bacteria or other substances into the uterus. This plug is expelled when cervical dilatation begins. Cervical changes associated with pregnancy include a bluish-purple discoloration of the cervix (Chadwick’s sign) from increased vascularization. Cervical changes associated with pregnancy include the softening of the cervix (Goodell’s sign) from increased vascularization and hypertrophy and engorgement of the vessels below the growing uterus. Colostrum does occur with pregnancy but is a physiological change associated with the breasts and not with a cervical change. Cullen’s sign is a bluish discoloration of the periumbilical skin caused by intraperitoneal hemorrhage. It can occur with a ruptured ectopic pregnancy or acute pancreatitis.
The nurse is taking the health history of the 40-year-old pregnant client. Which identified medical conditions increase the client’s risk for complications during her pregnancy? Select all that apply.
- A. Diabetes mellitus type 2
- B. Previous full-term pregnancy
- C. Controlled chronic hypertension
- D. New onset of iron-deficiency anemia
- E. Hemorrhage with a previous pregnancy
Correct Answer: A,C,D,E
Rationale: DM is a risk factor for complications such as preeclampsia, eclampsia, dystocia, fetal macrosomia, recurrent monilial vaginitis and UTIs, ketoacidosis, congenital abnormalities, and others. Controlled chronic hypertension may become uncontrolled during pregnancy due to water retention and other factors related to pregnancy. It is a risk factor for complications such as preeclampsia, placental abruption, and fetal hypoxia. Iron-deficiency anemia is associated with an increased incidence of preterm birth, low-birth-weight infants, and maternal and infant mortality. Previous pregnancy complications are a risk factor for complications. Having a previous full-term pregnancy is not a risk factor for a current pregnancy.
The nurse correctly explains that the bleeding is the result of sloughing of which structure?
- A. Endometrium
- B. Myometrium
- C. Epimetrium
- D. None of the above
Correct Answer: A
Rationale: Menstrual bleeding occurs due to the sloughing of the endometrium, the inner lining of the uterus, when pregnancy does not occur.
The nurse instructs the client with hyperemesis gravidarum to avoid which trigger?
- A. Eating small, frequent meals
- B. Strong odors
- C. High-protein foods
- D. Adequate hydration
Correct Answer: B
Rationale: Strong odors can exacerbate nausea and vomiting in hyperemesis gravidarum, worsening symptoms.
The pregnant client tells the nurse that she thinks she is carrying twins. In reviewing the client’s history and medical records, the nurse should determine that which factors are associated with a multiple gestation? Select all that apply.
- A. Elevated serum alpha-fetoprotein
- B. Use of reproductive technology
- C. Maternal age greater than 40
- D. History of twins in the family
- E. Elevated hemoglobin levels
Correct Answer: A,B,D
Rationale: An elevated serum alpha-fetoprotein level (an oncofetal protein normally produced by the fetal liver and yolk sac) is associated with a multiple gestation. The use of reproductive technology such as artificial insemination or fertility drugs is associated with a multiple gestation. History of twins in the family is associated with a multiple gestation. Maternal age greater than 40 is not associated with multiple gestation. An elevated Hgb is not associated with multiple gestation.