Nokea
The nurse teaches a pregnant woman about the presumptive, probable, and positive signs of pregnancy. The woman demonstrates understanding of the nurse's instructions if she states that a positive sign of pregnancy is:
- A. a positive pregnancy test
- B. fetal movement palpated by the nurse-midwife
- C. Braxton Hicks contractions
- D. quickening
Correct Answer: B
Rationale: Positive signs of pregnancy are attributed to the presence of a fetus, such as hearing the fetal heartbeat or palpating fetal movement. Presumptive and probable signs are less definitive.
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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.
During pregnancy, many changes occur as a direct result of the presence of the fetus. Which of these adaptations meet this criterion? (Select all that apply.)
- A. Leukorrhea
- B. Development of the operculum
- C. Quickening
- D. Ballottement
Correct Answer: B
Rationale: The correct answer is B: Development of the operculum. This adaptation refers to the formation of a mucus plug in the cervix during pregnancy, which helps protect the fetus from infections. It is a direct result of the presence of the fetus as it serves as a physical barrier.
A: Leukorrhea is the increased vaginal discharge during pregnancy, but it is not a direct result of the fetus presence.
C: Quickening is the first fetal movements felt by the mother, but it is a fetal activity, not a direct adaptation.
D: Ballottement is a palpation technique used to assess the fetus position, not an adaptation directly caused by the fetus.
What is the term for the step in maternal role attainment that relates to the woman giving up certain aspects of her previous life?
- A. Fantasy
- B. Grief work
- C. Role playing
- D. Looking for a fit
Correct Answer: B
Rationale: The correct answer is B: Grief work. In the process of maternal role attainment, giving up certain aspects of her previous life involves experiencing grief over the losses associated with the new role. This step is essential for the woman to fully embrace her new identity as a mother. Fantasy (A) refers to imagining scenarios, role playing (C) involves acting out behaviors, and looking for a fit (D) focuses on finding a balance between personal needs and the demands of the maternal role. Grief work is the most appropriate term that specifically addresses the emotional process of letting go and adjusting to the new responsibilities of motherhood.
Now in her second trimester of pregnancy, the client, who was a marathon runner before nausea and overwhelming tiredness kept her from exercising regularly, is wondering whether she can run now. What is the nurse's best response?
- A. Certainly, if you feel up to it.
- B. Your level of exercise will be somewhat modified by the changes occurring in your body.
- C. Your primary health care provider will need to give you permission.
- D. Because your body is meeting the needs of two people now, you should avoid too much exercise.
Correct Answer: B
Rationale: The correct answer is B: "Your level of exercise will be somewhat modified by the changes occurring in your body."
Rationale:
1. Pregnancy impacts a woman's body significantly, including changes in hormones, weight distribution, and center of gravity.
2. These changes can affect a woman's ability to engage in high-impact activities like running.
3. The nurse's response acknowledges the need for modification in exercise routine to accommodate these changes.
4. It promotes a balanced approach to exercise during pregnancy, considering both the benefits of physical activity and the safety of the mother and baby.
Summary of Other Choices:
A: "Certainly, if you feel up to it." - This response oversimplifies the situation and does not consider the specific physiological changes during pregnancy that may impact the woman's ability to run safely.
C: "Your primary health care provider will need to give you permission." - While consulting a healthcare provider is important, this response does not address the specific concerns related to exercise during pregnancy.
To reassure and educate their pregnant patients about changes in their blood pressure, maternity nurses should be aware that:
- A. a blood pressure cuff that is too small produces a reading that is too low; a cuff that is too large produces a reading that is too high.
- B. shifting the patient's position and changing from arm to arm for different measurements produces the most accurate composite blood pressure reading at each visit.
- C. the systolic blood pressure increases slightly as pregnancy advances; the diastolic pressure remains constant.
- D. compression of the iliac veins and inferior vena cava by the uterus contributes to hemorrhoids in the later stage of term pregnancy.
Correct Answer: D
Rationale: Compression of the iliac veins and inferior vena cava also leads to varicose veins in the legs and vulva.