A nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking
the client for probable signs of pregnancy. Select all probable signs of pregnancy. 1.Uterine enlargement
2.Fetal heart rate detected by nonelectric device
3.Outline of the fetus via radiography or ultrasound
4.Chadwick's sign
5.Braxton Hicks contractions
6.Ballottement - ans1, 4, 5, and 6. The probable signs of pregnancy include uterine enlargement, Hegar's sign
(softening and thinning of the uterine segment that occurs at week 6), Goodell's sign (softening of the cervix
that occurs at the beginning of the 2nd month), Chadwick's sign (bluish coloration of the mucous membranes
of the cervix, vagina, and vulva that occurs at week 6), ballottement (rebounding of the fetus against the
examiners fingers of palpation), Braxton Hicks contractions and a positive pregnancy test measuring for hCG.
Positive signs of pregnancy include fetal heart rate detected by electronic device (Doppler) at 10-12 weeks and
by nonelectronic device (fetoscope) at 20 weeks gestation, active fetal movements palpable by the examiner,
and an outline of the fetus via radiography or ultrasound.
1.21. Rho (D) immune globulin (RhoGAM) is prescribed for a woman following delivery of a newborn infant and
the nurse provides information to the woman about the purpose of the medication. The nurse determines that
the woman understands the purpose of the medication if the woman states that it will protect her next baby
from which of the following?
A.Being affected by Rh incompatibility
B.Having Rh positive blood
C.Developing a rubella infection
D.Developing physiological jaundice - ansA. Rh incompatibility can occur when an Rh-negative mom becomes
sensitized to the Rh antigen. Sensitization may develop when an Rh-negative woman becomes pregnant with a
fetus who is Rh positive. During pregnancy and at delivery, some of the baby's Rh positive blood can enter the
maternal circulation, causing the woman's immune system to form antibodies against Rh positive blood.
Administration of Rho (D) immune globulin prevents the woman from developing antibodies against Rh
A 21-year old client, 6 weeks' pregnant is diagnosed with hyperemesis gravidarum. This excessive vomiting
during pregnancy will often result in which of the following conditions?
A.Bowel perforation
B.Electrolyte imbalance
, C.Miscarriage
D.Pregnancy induced hypertension (PIH) - ansB. Excessive vomiting in clients with hyperemesis gravidarum
often causes weight loss and fluid, electrolyte, and acid-base imbalances.
A 26-year old multigravida is 14 weeks' pregnant and is scheduled for an alpha-fetoprotein test. She asks the
nurse, "What does the alpha-fetoprotein test indicate?" The nurse bases a response on the knowledge that this
test can detect:
A.Kidney defects
B.Cardiac defects
C.Neural tube defects
D.Urinary tract defects - ansC. The alpha-fetoprotein test detects neural tube defects and Down syndrome.
A client arrives at a prenatal clinic for the first prenatal assessment. The client tells a nurse that the first day of
her last menstrual period was September 19th, 2005. Using Nagele's rule, the nurse determines the estimated
date of confinement as:
1.July 26, 2006
2.June 12, 2007
3.June 26, 2006
4.July 12, 2007 - ans3. Accurate use of Nagele's rule requires that the woman have a regular 28-day menstrual
cycle. Add 7 days to the first day of the last menstrual period, subtract three months, and then add one year to
that date.
A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been
experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding
management of care. Which statement, if made by the client, indicates a need for further education?
1."I will maintain strict bedrest throughout the remainder of pregnancy."
2."I will avoid sexual intercourse until the bleeding has stopped, and for 2 weeks following the last evidence of
bleeding."
3."I will count the number of perineal pads used on a daily basis and note the amount and color of blood on
the pad."
4."I will watch for the evidence of the passage of tissue." - ans1. Strict bed rest throughout the remainder of