Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assisting with a prenatal examination of a client who is at 8 weeks of gestation. The nurse notes that the client's vagina and vulva are a purplish color. The nurse should document this finding as which of the following?
A. Ballottement
Ballottement refers to a palpable rebound of the fetus when the examiner pushes on the mother's abdomen.
B. Chadwick's sign
Chadwick's sign is a bluish or purplish discoloration of the cervix, vagina, and vulva that can occur during pregnancy. It is caused by increased blood flow and vascular changes in the area. It is considered a normal finding in early pregnancy and is often used as a sign to support the diagnosis of pregnancy.
C. Hegar's sign
Hegar's sign is the softening and compressibility of the lower uterine segment, which can be felt during a bimanual examination.
D. Chloasma
Chloasma refers to the development of hyperpigmented patches on the face, often referred to as the "mask of pregnancy."
This question is an excerpt from Nurse Dive's nursing test bank - PN Comprehensive Predictor PN 2020 Proctored Exam. Take the full exam now
Full Explanation
Chadwick's sign is a bluish or purplish discoloration of the cervix, vagina, and vulva that can occur during pregnancy. It is caused by increased blood flow and vascular changes in the area. It is considered a normal finding in early pregnancy and is often used as a sign to support the diagnosis of pregnancy.
Ballottement refers to a palpable rebound of the fetus when the examiner pushes on the mother's abdomen.
Hegar's sign is the softening and compressibility of the lower uterine segment, which can be felt during a bimanual examination.
Chloasma refers to the development of hyperpigmented patches on the face, often referred to as the "mask of pregnancy."
Similar Questions
A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation. Which of the following actions should the nurse take to promote progression toward independence and mobility for the client?
A. Encourage the client to use the overbed trapeze.
A nurse caring for a client who is 2 days postoperative following an above-the-knee amputation should encourage the client to use the overbed trapeze. This will promote independence and mobility by allowing the client to reposition themselves in bed and perform upper body exercises.
B. Maintain abduction of the client's residual limb with a pillow.
Maintaining abduction of the client's residual limb with a pillow can help prevent contractures, but it does not directly promote mobility.
C. Caution the client to avoid a prone position while in bed.
Cautioning the client to avoid a prone position while in bed is appropriate to prevent pressure injuries and promote healing, but it also does not directly promote mobility.
D. Keep a loose, absorbent dressing over the client's surgical site
Keeping a loose, absorbent dressing over the client's surgical site is important for infection control but does not promote mobility.
Full Explanation
A nurse caring for a client who is 2 days postoperative following an above-the-knee amputation should encourage the client to use the overbed trapeze. This will promote independence and mobility by allowing the client to reposition themselves in bed and perform upper body exercises.
Maintaining abduction of the client's residual limb with a pillow can help prevent contractures, but it does not directly promote mobility.
Cautioning the client to avoid a prone position while in bed is appropriate to prevent pressure injuries and promote healing, but it also does not directly promote mobility.
Keeping a loose, absorbent dressing over the client's surgical site is important for infection control but does not promote mobility.
A nurse is collecting data from a client who received oxytocin 10 units IM 30 min ago for excessive vaginal bleeding. Which of the following findings should the nurse expect?
A. Client report of burning with urination
B. Saturation of perineal pad in 15 min
C. Boggy fundus 3 fingerbreadths above the umbilicus
D. Client report of uterine cramping
Oxytocin is a medication commonly used to induce or enhance uterine contractions. Therefore, it is expected that the client may experience uterine cramping after receiving oxytocin. The medication helps to contract the uterus, which can aid in controlling excessive vaginal bleeding.
Full Explanation
Oxytocin is a medication commonly used to induce or enhance uterine contractions. Therefore, it is expected that the client may experience uterine cramping after receiving oxytocin. The medication helps to contract the uterus, which can aid in controlling excessive vaginal bleeding.
A nurse is caring for a client who was admitted for observation following a head injury. Which of the following findings by the nurse indicates the client is experiencing increased intracranial pressure?
A. Pin-point pupils
Pinpoint pupils are more commonly associated with opioid intoxication or damage to the pons rather than increased intracranial pressure (ICP). Increased ICP typically causes pupils to become dilated and sluggish or nonreactive to light.
B. Irritability
Irritability can be an early sign of increased intracranial pressure. As pressure within the skull rises, it can affect the brain's ability to function normally, leading to changes in behavior such as restlessness, agitation, or irritability.
C. Pallor
Pallor is not directly associated with increased intracranial pressure. It might indicate other issues such as anemia or poor circulation, but it is not a specific sign of increased ICP.
D. Decreased blood pressure
Increased intracranial pressure typically leads to hypertension (increased blood pressure) as part of the Cushing's triad, which includes hypertension, bradycardia, and irregular respirations. Decreased blood pressure would not be a typical finding associated with increased ICP.
Full Explanation
A. Pinpoint pupils are more commonly associated with opioid intoxication or damage to the pons rather than increased intracranial pressure (ICP). Increased ICP typically causes pupils to become dilated and sluggish or nonreactive to light
B. Irritability can be an early sign of increased intracranial pressure. As pressure within the skull rises, it can affect the brain's ability to function normally, leading to changes in behavior such as restlessness, agitation, or irritability.
C. Pallor is not directly associated with increased intracranial pressure. It might indicate other issues such as anemia or poor circulation, but it is not a specific sign of increased ICP.
D. Increased intracranial pressure typically leads to hypertension (increased blood pressure) as part of the Cushing's triad, which includes hypertension, bradycardia, and irregular respirations. Decreased blood pressure would not be a typical finding associated with increased ICP.