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The nurse is teaching a pregnant patient about signs of possible pregnancy complications. Which should the nurse include in the teaching plan? (Select all that apply.)
- A. Report watery vaginal discharge
- B. Report puffiness of the face or around the eyes.
- C. Report any bloody show when you go into labor.
- D. Report visual disturbances, such as spots before the eyes.
Correct Answer: A
Rationale: The correct answer is A: Report watery vaginal discharge. This is important as it could indicate premature rupture of membranes, which can lead to infection or preterm labor. Puffiness of the face or around the eyes (B) could be a sign of preeclampsia, not just a pregnancy complication. Bloody show during labor (C) is a normal sign of labor progression. Visual disturbances like spots (D) are more commonly associated with conditions like preeclampsia rather than general pregnancy complications.
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An 'average' menstrual cycle lasts around how many days?
- A. 36
- B. 28
- C. 42
- D. 7
Correct Answer: B
Rationale: The average menstrual cycle typically lasts about 28 days, though variations are common.
Which finding is a positive sign of pregnancy?
- A. Amenorrhea
- B. Breast changes
- C. Fetal movement felt by the woman
- D. Visualization of fetus by ultrasound
Correct Answer: B
Rationale: The correct answer is B: Breast changes. During pregnancy, hormonal changes cause breast enlargement, tenderness, and darkening of the areolas. This is considered a positive sign of pregnancy because it is a direct physiological response to the hormonal changes associated with pregnancy. Amenorrhea (choice A) is a common early sign of pregnancy but can also be due to other factors. Fetal movement (choice C) and visualization of fetus by ultrasound (choice D) are considered presumptive and probable signs of pregnancy, respectively, but not definitive positive signs like breast changes.
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: Auditory changes in the heart occur due to positional and structural changes during pregnancy. Sinus arrhythmia is common and benign unless accompanied by other symptoms.
A client in her third trimester reports increased perineal pressure. Which is the clinical cause for this complaint?
- A. Fundal height
- B. Urinary infection
- C. Constipation
- D. Hydramnios
Correct Answer: A
Rationale: The correct answer is A: Fundal height. In the third trimester, the growing uterus causes increased pressure on the pelvic organs, leading to perineal pressure. Fundal height measures the height of the uterus and correlates with gestational age, indicating the position and size of the fetus. As the uterus grows, fundal height increases, causing pressure on the perineal area. Urinary infection (B) can cause discomfort but would present with other symptoms like burning urination. Constipation (C) may cause discomfort but typically does not lead to increased perineal pressure. Hydramnios (D) refers to excess amniotic fluid, which can lead to abdominal distension but is not directly related to perineal pressure.
A woman is in her seventh month of pregnancy. She has been reporting nasal congestion and occasional epistaxis. The nurse suspects that:
- A. this is a normal respiratory change in pregnancy caused by elevated levels of estrogen.
- B. this is an abnormal cardiovascular change, and the nosebleeds are an ominous sign.
- C. the woman is a victim of domestic violence and is being hit in the face by her partner.
- D. the woman has been using cocaine intranasally.
Correct Answer: A
Rationale: Rationale:
A: Correct. Nasal congestion and epistaxis are common in pregnancy due to increased estrogen causing mucosal swelling and vasodilation.
B: Incorrect. Nosebleeds are not typically indicative of cardiovascular issues in pregnancy.
C: Incorrect. There is no evidence to suggest domestic violence based on the symptoms provided.
D: Incorrect. Cocaine use would have more severe implications beyond just nasal congestion and epistaxis in pregnancy.