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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: Auscultatory changes should be discernible after 20 weeks of gestation.
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To reassure and educate pregnant patients about changes in the uterus, nurses should be aware that:
- A. lightening occurs near the end of the second trimester as the uterus rises into a different position.
- B. the woman's increased urinary frequency in the first trimester is the result of exaggerated uterine anteflexion caused by softening.
- C. Braxton Hicks contractions become more painful in the third trimester, particularly if the woman tries to exercise.
- D. the uterine souffle is the movement of the fetus.
Correct Answer: B
Rationale: The softening of the lower uterine segment is called Hegar's sign. Lightening occurs in the last 2 weeks of pregnancy, when the fetus descends.
Mastitis is:
- A. Inflammation of the testes
- B. A condition that causes a woman's breast tissue to become painful and inflamed
- C. Often caused by too much calcium in the diet
Correct Answer: B
Rationale: Mastitis is inflammation of the breast tissue, often due to infection or blocked milk ducts during breastfeeding.
A pregnant patient comes into the medical clinic stating that her family and friends are telling
her that she is always talking about the pregnancy and nothing else. She is concerned that
something is wrong with her. What psychological behavior is she exhibiting?
- A. Antepartum obsession
- B. Ambivalence
- C. Uncertainty
- D. Uncertainty
Correct Answer: D
Rationale: The correct answer is D: Uncertainty. The patient is exhibiting psychological behavior characterized by doubt and indecision regarding her pregnancy. This is evident by her concern and the feedback she is receiving from her family and friends.
A: Antepartum obsession is not the correct choice as the patient is not displaying an obsessive preoccupation with her pregnancy.
B: Ambivalence is not the correct choice as it refers to conflicting feelings or thoughts, which are not explicitly mentioned in the scenario.
C: Uncertainty is essentially the same as choice D, which is the correct answer.
In summary, the patient's behavior aligns with uncertainty as she is expressing doubt and worry about her excessive focus on her pregnancy.
The experienced nurse is instructing the new nurse about communications concerning the patient. The nurse suggests using an SBAR method and lists the four elements included in the technique. Which four elements should be included in the instruction?
- A. Shift-end report, background, assessment, and reassessment
- B. Situation, background, assessment, and recommendation
- C. Shift-end report, background, assessment, and recommendation
- D. Situation, background, actual nursing diagnoses, and remedy
Correct Answer: B
Rationale: SBAR stands for Situation, Background, Assessment, and Recommendation. This method is widely used in healthcare settings to ensure clear and concise communication.
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: The correct answer is B: fetal movement palpated by the nurse-midwife. This is a positive sign of pregnancy because it is a direct indication of the presence of a fetus. Fetal movements can only be felt once the baby has developed enough to be physically palpable, typically around 18-20 weeks of gestation. This sign is considered reliable and conclusive evidence of pregnancy.
A: A positive pregnancy test is a presumptive sign, as it indicates the possibility of pregnancy but is not definitive.
C: Braxton Hicks contractions are probable signs, as they are common in pregnancy but do not confirm the presence of a fetus.
D: Quickening, the mother's first perception of fetal movements, is a probable sign and does not provide definitive proof of pregnancy.