Nokea
Probable signs of pregnancy
- A. Ballottement (rebounding of the fetus against the examiner's fingers on palpation)
- B. Chadwicks sign (violet coloration of mucous membranes of cervix, vagina, and vulva @4 wks)
- C. Uterine enlargement
- D. Hegar's sign (compressibility and softening of lower uterine segment @6 wks)
Correct Answer: A
Rationale: The correct answer is A: Ballottement. This is a probable sign of pregnancy because it involves the rebounding of the fetus against the examiner's fingers on palpation. This occurs when the examiner pushes against the uterus and feels a bouncing back, indicating the presence of a fetus.
Choice B, Chadwick's sign, is actually the violet coloration of mucous membranes of cervix, vagina, and vulva at around 6-8 weeks, not 4 weeks as stated.
Choice C, uterine enlargement, is a presumptive sign of pregnancy as it can be caused by factors other than pregnancy, such as fibroids.
Choice D, Hegar's sign, involves the compressibility and softening of the lower uterine segment at around 6 weeks, but it is a probable sign rather than a definitive one like Ballottement.
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A postpartum client is getting ready to receive a Depo-Provera injection. Which statement by the client indicates that further teaching by the nurse is necessary?
- A. You will give this shot just like the rubella injection I received yesterday.
- B. I will watch my weight and try to exercise daily after receiving this injection.
- C. I will need to reschedule a follow-up appointment in 3 months.
- D. It might take me a year to get pregnant after receiving this type of birth control.
Correct Answer: A
Rationale: The correct answer is A because the client's comparison of receiving a Depo-Provera injection to a rubella injection is incorrect. Depo-Provera is a hormonal contraceptive injection that does not have the same administration process or purpose as a rubella vaccination. This indicates a lack of understanding about the medication.
Choice B is not the correct answer because it shows the client's awareness of the importance of weight management and exercise in conjunction with receiving the injection.
Choice C is not the correct answer because it demonstrates the client's understanding of the need for a follow-up appointment in 3 months which is necessary for monitoring and continuation of the contraceptive method.
Choice D is not the correct answer because it shows the client's understanding of the potential delay in fertility after discontinuing Depo-Provera, which is an important aspect of the contraceptive method that the client should be aware of.
The nurse is caring for a client in labor with ruptured membranes. What finding suggests umbilical cord prolapse?
- A. Clear amniotic fluid.
- B. Variable decelerations on the fetal monitor.
- C. Contractions every 2 minutes.
- D. Maternal blood pressure of 110/70 mmHg.
Correct Answer: B
Rationale: The correct answer is B: Variable decelerations on the fetal monitor. This finding suggests umbilical cord prolapse because the cord can become compressed during contractions, leading to variable decelerations. It is a serious complication that requires immediate intervention to prevent fetal distress.
A: Clear amniotic fluid is a normal finding after rupture of membranes.
C: Contractions every 2 minutes may indicate tachysystole, but not specifically cord prolapse.
D: Maternal blood pressure is not directly related to cord prolapse.
The nurse is caring for a client with suspected preterm labor. Which medication is most likely to be prescribed?
- A. Magnesium sulfate.
- B. Methyldopa.
- C. Rho(D) immune globulin.
- D. Oxytocin.
Correct Answer: A
Rationale: The correct answer is A: Magnesium sulfate. This medication is commonly prescribed for preterm labor to relax the uterine muscles and prevent contractions. It helps delay labor and reduce the risk of preterm birth. Methyldopa (B) is used for managing hypertension, not preterm labor. Rho(D) immune globulin (C) is given to Rh-negative mothers to prevent hemolytic disease in newborns. Oxytocin (D) is used to induce or augment labor, not for suspected preterm labor. Therefore, A is the most appropriate choice for managing preterm labor.
The nurse is monitoring a client with severe preeclampsia. What finding requires immediate intervention?
- A. Proteinuria of +1.
- B. Respiratory rate of 16 breaths per minute.
- C. Deep tendon reflexes +4.
- D. Urine output of 50 mL/hour.
Correct Answer: C
Rationale: The correct answer is C: Deep tendon reflexes +4. In severe preeclampsia, increased reflexes indicate possible progression to eclampsia with seizures. Immediate intervention is needed to prevent seizures. Choice A is not urgent unless higher proteinuria levels are present. Choice B is within normal range. Choice D is concerning but not as urgent as managing potential seizures.
Which assessment finding indicates uterine rupture?
- A. Contractions abruptly stop during labor
- B. Decreased maternal heart rate
- C. Gradual onset of mild pain during contractions
- D. Uterus becomes firm between contractions
Correct Answer: A
Rationale: The correct answer is A: Contractions abruptly stop during labor. Uterine rupture is a serious obstetric emergency where the integrity of the uterus is compromised, leading to potential life-threatening complications for both the mother and the fetus. When the uterus ruptures, contractions may abruptly stop due to the loss of muscle tone and coordination. This sudden cessation of contractions is a red flag indicating uterine rupture.
Choice B, decreased maternal heart rate, is not typically associated with uterine rupture. Choice C, gradual onset of mild pain during contractions, is more indicative of a normal labor process rather than uterine rupture. Choice D, uterus becomes firm between contractions, is not a specific sign of uterine rupture as it can occur in normal labor as well.