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Which time-based description of a stage of development in pregnancy is accurate?
- A. Viability—22 to 37 weeks since the last menstrual period (LMP) (assuming a fetal weight >500 g).
- B. Full Term—Pregnancy from the beginning of week 39 of gestation to the end of week 40.
- C. Preterm—Pregnancy from 20 to 28 weeks.
- D. Postdate—Pregnancy that extends beyond 38 weeks.
Correct Answer: B
Rationale: Full Term is 39 to 40 weeks of gestation.
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During a patient's physical examination the nurse notes that the lower uterine segment is soft on palpation. The nurse would document this finding as:
- A. Hegar's sign.
- B. McDonald's sign.
- C. Chadwick's sign.
- D. Goodell's sign.
Correct Answer: C
Rationale: The correct answer is C: Chadwick's sign. This sign refers to the bluish discoloration of the cervix and vagina due to increased vascularity in early pregnancy. The lower uterine segment being soft on palpation is consistent with Chadwick's sign, indicating early signs of pregnancy.
A: Hegar's sign refers to softening of the lower uterine segment, not the cervix or vagina.
B: McDonald's sign is the softening of the uterus at the isthmus, not specifically at the lower uterine segment.
D: Goodell's sign pertains to softening of the cervix, not the lower uterine segment.
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.
Which time-based description of a stage of development in pregnancy is accurate?
- A. Viability-22 to 37 weeks since the last menstrual period (LMP) (assuming a fetal weight >500 g).
- B. Full Term-Pregnancy from the beginning of week 39 of gestation to the end of week 40
- C. Preterm-Pregnancy from 20 to 28 weeks.
- D. Postdate-Pregnancy that extends beyond 38 weeks.
Correct Answer: B
Rationale: The correct answer is B: Full Term-Pregnancy from the beginning of week 39 of gestation to the end of week 40. This is accurate because full-term pregnancy typically ranges from 39 to 40 weeks of gestation, which is considered the optimal time for a baby to be born in terms of development and health. Viability (Choice A) refers to the ability of a fetus to survive outside the womb and typically occurs between 22 to 37 weeks. Preterm (Choice C) describes a pregnancy that occurs before 37 weeks. Postdate (Choice D) refers to a pregnancy that extends beyond 40 weeks. Therefore, Choices A, C, and D are incorrect as they do not accurately describe the full-term stage of pregnancy.
A 31-year-old woman believes that she may be pregnant. She took an OTC pregnancy test 1 week ago after missing her period; the
test was positive. During her assessment interview, the nurse enquires about the woman’s last menstrual period and asks whether
she is taking any medications. The woman states that she takes medicine for epilepsy. She has been under considerable stress lately
at work and has not been sleeping well. She also has a history of irregular periods. Her physical examination does not indicate that
she is pregnant. She has an ultrasound scan that reveals she is not pregnant. What is the most likely cause of the false-positive
pregnancy test result?
- A. She took the pregnancy test too early.
- B. She takes anticonvulsants.
- C. She has a fibroid tumor.
- D. She has been under considerable stress and has a hormone imbalance
Correct Answer: B
Rationale: The correct answer is B: She takes anticonvulsants. Anticonvulsants can interfere with pregnancy test results by causing false-positive results. Here's a step-by-step rationale:
1. Anticonvulsants, such as phenytoin and phenobarbital, contain hCG-like substances that can cross-react with pregnancy tests, leading to false-positive results.
2. The woman's history of epilepsy medication use suggests that she may be taking anticonvulsants, which could be the reason for the false-positive pregnancy test result.
3. Other choices are incorrect:
A: Taking the test too early is unlikely since a week has passed since the missed period.
C: Fibroid tumors do not typically cause false-positive pregnancy test results.
D: Stress and hormone imbalance could impact menstrual cycles but are less likely to directly affect pregnancy test results.
The nurse admitting a 3-year-old patient with the medical diagnosis of pneumonia identifies congestion and inspiratory wheezes in both lungs. This information is considered part of which step of the nursing process?
- A. Diagnosis
- B. Evaluation
- C. Assessment
- D. Implementation
Correct Answer: C
Rationale: Identifying symptoms such as congestion and wheezing is part of the assessment phase of the nursing process, where data is collected and analyzed.