Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse teaches a pregnant woman about the presumptive, probable, and positive signs of pregnancy. The woman demonstrates an understanding of the nurse's instructions if she states that a positive sign of pregnancy is:
A. quickening.
Quickening is the first perception of fetal movement by the mother, usually occurring between 16 and 20 weeks of gestation. It is a presumptive sign of pregnancy, as it can be subjective and influenced by other factors such as gas or peristalsis.
B. a positive pregnancy test.
A positive pregnancy test is a probable sign of pregnancy, as it indicates the presence of human chorionic gonadotropin (hCG) in the urine or blood. However, it is not conclusive, as it can be affected by false positives or false negatives, or by other conditions that produce hCG.
C. Braxton Hicks contractions.
Braxton Hicks contractions are irregular, painless uterine contractions that occur throughout pregnancy. They are a probable sign of pregnancy, as they indicate uterine activity and preparation for labor. However, they are not diagnostic, as they can also occur in non-pregnant women or in response to other stimuli.
D. fetal movement palpated by the nurse-midwife.
Fetal movement palpated by the nurse-midwife is a positive sign of pregnancy, as it confirms the presence of a living fetus in the uterus. It is an objective and reliable sign that can be detected by a skilled examiner after 20 weeks of gestation.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Maternal Newborn Midterm Proctored Exam 1. Take the full exam now
Full Explanation
Choice A reason: Quickening is the first perception of fetal movement by the mother, usually occurring between 16 and 20 weeks of gestation. It is a presumptive sign of pregnancy, as it can be subjective and influenced by other factors such as gas or peristalsis.
Choice B reason: A positive pregnancy test is a probable sign of pregnancy, as it indicates the presence of human chorionic gonadotropin (hCG) in the urine or blood. However, it is not conclusive, as it can be affected by false positives or false negatives, or by other conditions that produce hCG.
Choice C reason: Braxton Hicks contractions are irregular, painless uterine contractions that occur throughout pregnancy. They are a probable sign of pregnancy, as they indicate uterine activity and preparation for labor. However, they are not diagnostic, as they can also occur in non-pregnant women or in response to other stimuli.
Choice D reason: Fetal movement palpated by the nurse-midwife is a positive sign of pregnancy, as it confirms the presence of a living fetus in the uterus. It is an objective and reliable sign that can be detected by a skilled examiner after 20 weeks of gestation.
Similar Questions
A pregnant woman experiencing nausea and vomiting should:
A. limit fluid intake throughout the day.
Limiting fluid intake throughout the day is not recommended, as dehydration can worsen nausea and vomiting. Instead, pregnant women should sip fluids gradually throughout the day to maintain hydration. Proper hydration supports digestion and helps prevent complications like electrolyte imbalances. Clinical guidelines emphasize the importance of maintaining adequate fluid intake during pregnancy
B. drink a glass of water with a fat-free carbohydrate before getting out of bed in the morning.
Drinking a glass of water with a fat-free carbohydrate before getting out of bed in the morning is a good strategy to prevent nausea and vomiting, as it can stabilize the blood sugar level and prevent an empty stomach. However, it is not the best answer, as it does not address the dietary needs throughout the day.
C. increase her intake of high-fat foods to keep the stomach full and coated.
Increasing the intake of high-fat foods is not recommended, as it can worsen nausea and vomiting. High-fat foods are harder to digest and can cause gastric irritation and reflux. The pregnant woman should choose low-fat, bland, and easy-to-digest foods.
D. eat small, frequent meals (every 2 to 3 hours).
Eating small, frequent meals every 2 to 3 hours is the best approach to managing nausea and vomiting during pregnancy. This strategy helps stabilize blood sugar levels and prevents the stomach from becoming too empty or too full, both of which can trigger nausea. Clinical guidelines widely support this dietary adjustment as a primary intervention for nausea and vomiting in pregnancy
Full Explanation
Choice A reason: Limiting fluid intake throughout the day is not recommended, as dehydration can worsen nausea and vomiting. Instead, pregnant women should sip fluids gradually throughout the day to maintain hydration. Proper hydration supports digestion and helps prevent complications like electrolyte imbalances. Clinical guidelines emphasize the importance of maintaining adequate fluid intake during pregnancy
Choice B reason: Drinking a glass of water with a fat-free carbohydrate before getting out of bed in the morning is a good strategy to prevent nausea and vomiting, as it can stabilize the blood sugar level and prevent an empty stomach. However, it is not the best answer, as it does not address the dietary needs throughout the day.
Choice C reason: Increasing the intake of high-fat foods is not recommended, as it can worsen nausea and vomiting. High-fat foods are harder to digest and can cause gastric irritation and reflux. The pregnant woman should choose low-fat, bland, and easy-to-digest foods.
Choice D reason: Eating small, frequent meals every 2 to 3 hours is the best approach to managing nausea and vomiting during pregnancy. This strategy helps stabilize blood sugar levels and prevents the stomach from becoming too empty or too full, both of which can trigger nausea. Clinical guidelines widely support this dietary adjustment as a primary intervention for nausea and vomiting in pregnancy
A woman with severe preeclampsia is receiving a magnesium sulfate infusion. The nurse becomes concerned after assessment when the woman exhibits:
A. a sleepy, sedated affect.
A sleepy, sedated affect is not a concerning sign, as it is a common side effect of magnesium sulfate. Magnesium sulfate is a central nervous system depressant that can cause drowsiness, lethargy, and reduced alertness.
B. absent ankle clonus.
Absent ankle clonus is not a concerning sign, as it indicates a normal neuromuscular response. Ankle clonus is a rhythmic jerking of the foot when the ankle is dorsiflexed. It is a sign of hyperreflexia, which can occur in severe preeclampsia due to increased blood pressure and cerebral edema.
C. a respiratory rate of 10 breaths/min.
A respiratory rate of 10 breaths/min is a concerning sign, as it indicates respiratory depression. This is a serious complication of magnesium sulfate toxicity, which can lead to respiratory arrest and death. The nurse should monitor the woman's respiratory rate closely and report any signs of respiratory distress.
D. deep tendon reflexes of 2+.
Deep tendon reflexes of 2+ are not a concerning sign, as they indicate a normal neuromuscular response. Deep tendon reflexes are graded from 0 to 4, with 2 being the average. Magnesium sulfate can cause hyporeflexia or areflexia, which are signs of magnesium sulfate toxicity.
Full Explanation
Choice A reason: A sleepy, sedated affect is not a concerning sign, as it is a common side effect of magnesium sulfate. Magnesium sulfate is a central nervous system depressant that can cause drowsiness, lethargy, and reduced alertness.
Choice B reason: Absent ankle clonus is not a concerning sign, as it indicates a normal neuromuscular response. Ankle clonus is a rhythmic jerking of the foot when the ankle is dorsiflexed. It is a sign of hyperreflexia, which can occur in severe preeclampsia due to increased blood pressure and cerebral edema.
Choice C reason: A respiratory rate of 10 breaths/min is a concerning sign, as it indicates respiratory depression. This is a serious complication of magnesium sulfate toxicity, which can lead to respiratory arrest and death. The nurse should monitor the woman's respiratory rate closely and report any signs of respiratory distress.
Choice D reason: Deep tendon reflexes of 2+ are not a concerning sign, as they indicate a normal neuromuscular response. Deep tendon reflexes are graded from 0 to 4, with 2 being the average. Magnesium sulfate can cause hyporeflexia or areflexia, which are signs of magnesium sulfate toxicity.
Which viral sexually transmitted infection is characterized by a primary infection followed by recurrent episodes?
A. Human immunodeficiency virus (HIV)
Human immunodeficiency virus (HIV) is a viral sexually transmitted infection that causes acquired immunodeficiency syndrome (AIDS). It is characterized by a progressive decline of the immune system, leading to opportunistic infections and cancers. It does not have recurrent episodes, but rather a chronic and incurable course.
B. Herpes simplex virus (HSV)-2
Herpes simplex virus (HSV)-2 is a viral sexually transmitted infection that causes genital herpes. It is characterized by a primary infection followed by recurrent episodes of painful blisters and ulcers in the genital area. The virus remains latent in the nerve cells and can reactivate periodically or in response to triggers such as stress, illness, or menstruation.
C. Human papillomavirus (HPV)
Human papillomavirus (HPV) is a viral sexually transmitted infection that causes genital warts and cervical cancer. It is characterized by a persistent infection that may or may not produce symptoms. It does not have recurrent episodes, but rather a variable and unpredictable course.
D. Cytomegalovirus (CMV)
Cytomegalovirus (CMV) is a viral sexually transmitted infection that causes mild or asymptomatic infections in healthy adults. It is characterized by a latent infection that can reactivate in immunocompromised individuals, causing serious complications such as retinitis, pneumonia, or encephalitis. It does not have recurrent episodes, but rather a dormant and opportunistic course.
Full Explanation
Choice A reason: Human immunodeficiency virus (HIV) is a viral sexually transmitted infection that causes acquired immunodeficiency syndrome (AIDS). It is characterized by a progressive decline of the immune system, leading to opportunistic infections and cancers. It does not have recurrent episodes, but rather a chronic and incurable course.
Choice B reason: Herpes simplex virus (HSV)-2 is a viral sexually transmitted infection that causes genital herpes. It is characterized by a primary infection followed by recurrent episodes of painful blisters and ulcers in the genital area. The virus remains latent in the nerve cells and can reactivate periodically or in response to triggers such as stress, illness, or menstruation.
Choice C reason: Human papillomavirus (HPV) is a viral sexually transmitted infection that causes genital warts and cervical cancer. It is characterized by a persistent infection that may or may not produce symptoms. It does not have recurrent episodes, but rather a variable and unpredictable course.
Choice D reason: Cytomegalovirus (CMV) is a viral sexually transmitted infection that causes mild or asymptomatic infections in healthy adults. It is characterized by a latent infection that can reactivate in immunocompromised individuals, causing serious complications such as retinitis, pneumonia, or encephalitis. It does not have recurrent episodes, but rather a dormant and opportunistic course.