Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse in a prenatal clinic is caring for a client who believes she might be pregnant because she feels the baby moving.Which statement should the nurse make?
A. “This is a probable sign of pregnancy.”.
A probable sign of pregnancy includes objective signs observed by an examiner, such as changes in the pelvic organs, enlargement of the abdomen, and positive pregnancy test.
B. “This is a possible sign of pregnancy.”.
Possible signs of pregnancy are those that are subjective and reported by the patient, such as nausea, vomiting, and missed period. These signs could be due to other conditions.
C. “This is a presumptive sign of pregnancy.”.
Feeling the baby moving, also known as quickening, is a presumptive sign of pregnancy. These are changes felt by the woman herself and can be caused by other conditions.
D. “This is a positive sign of pregnancy.”.
Positive signs of pregnancy are those that are confirmed by the examiner and cannot be caused by any other condition. These include hearing the fetal heartbeat, visualizing the fetus, and feeling the baby move.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Nur 232 Maternity Final Proctored Exam Sp24. Take the full exam now
Full Explanation
Choice A rationale
A probable sign of pregnancy includes objective signs observed by an examiner, such as changes in the pelvic organs, enlargement of the abdomen, and positive pregnancy test.
Choice B rationale
Possible signs of pregnancy are those that are subjective and reported by the patient, such as nausea, vomiting, and missed period. These signs could be due to other conditions.
Choice C rationale
Feeling the baby moving, also known as quickening, is a presumptive sign of pregnancy. These are changes felt by the woman herself and can be caused by other conditions.
Choice D rationale
Positive signs of pregnancy are those that are confirmed by the examiner and cannot be caused by any other condition. These include hearing the fetal heartbeat, visualizing the fetus, and feeling the baby move.
Similar Questions
A nurse is caring for a newborn and assessing newborn reflexes.
To elicit the Moro reflex, what action should the nurse take?
A. Turn the newborn’s head quickly to one side.
Turning the newborn’s head quickly to one side does not elicit the Moro reflex. This action can elicit the tonic neck reflex, also known as the “fencing” reflex.
B. Perform a sharp hand clap near the infant.
Performing a sharp hand clap near the infant can elicit the Moro reflex. This reflex is a response to a sudden loss of support and involves three distinct components: spreading out the arms (abduction), unspreading the arms (adduction), and usually crying.
C. Place a finger at the base of the newborn’s toes.
Placing a finger at the base of the newborn’s toes elicits the Babinski reflex, not the Moro reflex.
D. Hold the newborn vertically allowing one foot to touch the table surface.
Holding the newborn vertically allowing one foot to touch the table surface does not elicit the Moro reflex. This action can elicit the stepping or walking reflex.
Full Explanation
Choice A rationale
Turning the newborn’s head quickly to one side does not elicit the Moro reflex. This action can elicit the tonic neck reflex, also known as the “fencing” reflex.
Choice B rationale
Performing a sharp hand clap near the infant can elicit the Moro reflex. This reflex is a response to a sudden loss of support and involves three distinct components: spreading out the arms (abduction), unspreading the arms (adduction), and usually crying.
Choice C rationale
Placing a finger at the base of the newborn’s toes elicits the Babinski reflex, not the Moro reflex.
Choice D rationale
Holding the newborn vertically allowing one foot to touch the table surface does not elicit the Moro reflex. This action can elicit the stepping or walking reflex.
A nurse is caring for a client who is 5 hours postpartum following a vaginal birth of a newborn weighing 9 lb 6 oz. (4252 g). The nurse should recognize that this client is at risk for which postpartum complications?
A. Thrombophlebitis.
Thrombophlebitis is a condition where a blood clot in a vein causes inflammation and pain. While it can occur postpartum, it is not directly related to the weight of the newborn.
B. Retained placental fragments.
Retained placental fragments can occur after childbirth and can lead to postpartum hemorrhage or infection. However, this complication is not directly related to the weight of the newborn.
C. Puerperal infection.
Puerperal infection, also known as postpartum infection, can occur after childbirth. However, it is not directly related to the weight of the newborn.
D. Uterine atony.
Uterine atony, a condition where the uterus fails to contract after the delivery of the baby, is a common cause of postpartum hemorrhage. A larger newborn, such as one weighing 9 lb 6 oz, can overstretch the uterus, increasing the risk of uterine atony.
Full Explanation
Choice A rationale
Thrombophlebitis is a condition where a blood clot in a vein causes inflammation and pain. While it can occur postpartum, it is not directly related to the weight of the newborn.
Choice B rationale
Retained placental fragments can occur after childbirth and can lead to postpartum hemorrhage or infection. However, this complication is not directly related to the weight of the newborn.
Choice C rationale
Puerperal infection, also known as postpartum infection, can occur after childbirth. However, it is not directly related to the weight of the newborn.
Choice D rationale
Uterine atony, a condition where the uterus fails to contract after the delivery of the baby, is a common cause of postpartum hemorrhage. A larger newborn, such as one weighing 9 lb 6 oz, can overstretch the uterus, increasing the risk of uterine atony.
What could be the primary reason for early decelerations in the fetal heart rate (FHR) pattern?
A. Spontaneous rupture of membranes.
Early decelerations in the fetal heart rate (FHR) are caused by compression of the fetus’s head during a uterine contraction. This often happens during later stages of labor as the baby is descending through the birth canal. They may also occur during early labor if the baby is premature or in a breech position. This causes the uterus to squeeze the head during contractions.
B. Uteroplacental insufficiency.
Uteroplacental insufficiency is a condition where the placenta does not provide enough oxygen and nutrients to the fetus. This condition is typically associated with late decelerations in the FHR, not early decelerations.
C. Altered fetal cerebral blood flow.
Altered fetal cerebral blood flow is not typically associated with early decelerations in the FHR34.
D. Umbilical cord compression.
Umbilical cord compression is typically associated with variable decelerations in the FHR, not early decelerations.
Full Explanation
Choice A rationale
Early decelerations in the fetal heart rate (FHR) are caused by compression of the fetus’s head during a uterine contraction. This often happens during later stages of labor as the baby is descending through the birth canal. They may also occur during early labor if the baby is premature or in a breech position. This causes the uterus to squeeze the head during contractions.
Choice B rationale
Uteroplacental insufficiency is a condition where the placenta does not provide enough oxygen and nutrients to the fetus. This condition is typically associated with late decelerations in the FHR, not early decelerations.
Choice C rationale
Altered fetal cerebral blood flow is not typically associated with early decelerations in the FHR34.
Choice D rationale
Umbilical cord compression is typically associated with variable decelerations in the FHR, not early decelerations.