Nokea
The nurse notes each of the following findings in a 10-week gestation client. Which of the findings would enable the nurse to tell the client that she is positively pregnant?
- A. Fetal heart rate via Doppler.
- B. Positive pregnancy test.
- C. Positive Chadwick’s sign.
- D. Montgomery gland enlargements.
Correct Answer: A
Rationale: A fetal heart rate detected via Doppler is a positive sign of pregnancy. A positive pregnancy test, Chadwick’s sign, and Montgomery gland enlargements are probable signs but not definitive.
You may also like to solve these questions
The nurse midwife tells a client that the baby is growing and that ballottement was evident during the vaginal examination. How should the nurse explain what the nurse midwife means by ballottement?
- A. The nurse midwife saw that the mucous plug was intact.
- B. The nurse midwife felt the baby rebound after being pushed.
- C. The nurse midwife palpated the fetal parts through the uterine wall.
- D. The nurse midwife assessed that the baby is head down.
Correct Answer: B
Rationale: Ballottement is the rebound of the fetus when it is pushed during a vaginal examination, indicating fetal movement and growth.
An antenatal client is informing the nurse of her prenatal signs and symptoms. Which of the following findings would the nurse determine are presumptive signs of pregnancy? Select all that apply.
- A. Amenorrhea.
- B. Breast tenderness.
- C. Quickening.
- D. Frequent urination.
Correct Answer: A
Rationale: Presumptive signs of pregnancy are subjective and include amenorrhea, breast tenderness, quickening, and frequent urination. Uterine growth is a probable sign of pregnancy.
What fetal change occurs when the fundal height reaches the xiphoid process?
- A. Surfactant forms in lungs
- B. Eyes begin to open and close
- C. Respiratory movements begin
- D. Spinal column is complete
Correct Answer: A
Rationale: Surfactant production begins in the lungs around this stage of pregnancy, preparing them for postnatal breathing.
A woman in her third trimester advises the nurse that she wishes to breastfeed her baby, 'but I don’t think my nipples are right.' Upon examination, the nurse notes that the client has inverted nipples. Which of the following actions should the nurse take at this time?
- A. Advise the client that it is unlikely that she will be able to breastfeed.
- B. Refer the client to a lactation consultant for advice.
- C. Call the labor room and notify them that a client with inverted nipples will be admitted.
- D. Teach the woman exercises to exert her nipples.
Correct Answer: B
Rationale: Inverted nipples can make breastfeeding challenging, but with proper guidance from a lactation consultant, many women are able to breastfeed successfully. Exercises to exert the nipples may also be helpful, but referral to a specialist is the best initial action.
A nurse is caring for a pregnant patient who is at 40 weeks gestation and reports leaking clear fluid. What is the nurse's priority action?
- A. Check the fetal heart rate and assess the mother's vital signs.
- B. Encourage the patient to go home and rest until contractions begin.
- C. Instruct the patient to monitor fetal movement and call back if the fluid continues to leak.
- D. Call the healthcare provider immediately to report the rupture of membranes.
Correct Answer: D
Rationale: The correct answer is D because the nurse's priority action in this scenario is to report the rupture of membranes to the healthcare provider immediately. This is crucial to ensure timely assessment and management to prevent infection and monitor for potential complications. Checking fetal heart rate and vital signs (A) can be important but not as urgent as reporting the rupture of membranes. Encouraging the patient to go home and rest (B) is inappropriate as leaking clear fluid at 40 weeks gestation may indicate rupture of membranes. Instructing the patient to monitor fetal movement and call back (C) is not sufficient as immediate medical attention is needed in case of ruptured membranes.