Which of the following would the nurse identify as a presumptive sign of pregnancy?
-
Solution
Nausea and vomiting
Presumptive signs of pregnancy are subjective signs. Of the signs listed, only nausea and vomiting are presumptive signs.
Options A, C, and D: Hegar sign, skin pigmentation changes, and a positive serum pregnancy test are considered probably signs, which are strongly suggestive of pregnancy.
Cervical softening and uterine souffle are classified as which of the following?
-
Solution
Probable signs
Cervical softening (Goodell sign) and uterine soufflé are two probable signs of pregnancy. Probable signs are objective findings that strongly suggest pregnancy. Other probable signs include Hegar sign, which is softening of the lower uterine segment; Piskacek sign, which is an enlargement and softening of the uterus; serum laboratory tests; changes in skin pigmentation; and ultrasonic evidence of a gestational sac.
Option B: Presumptive signs are subjective signs and include amenorrhea; nausea and vomiting; urinary frequency; breast tenderness and changes; excessive fatigue; uterine enlargement; and quickening.
When talking with a pregnant client who is experiencing aching swollen, leg veins, the nurse would explain that this is most probably the result of which of the following?
-
Solution
Pressure on blood vessels from the enlarging uterus
The pressure of the growing uterus on blood vessels results in an increased risk for venous stasis in the lower extremities. Subsequently, edema and varicose vein formation may occur.
Option A: Thrombophlebitis is an inflammation of the veins due to thrombus formation.
Option B: Pregnancy-induced hypertension is not associated with these symptoms.
Option D: Gravity plays only a minor role with these symptoms.
Which of the following represents the average amount of weight gained during pregnancy?
-
Solution
24 to 30 lb
The average amount of weight gained during pregnancy is 24 to 30 lb. This weight gain consists of the following: fetus – 7.5 lb; placenta and membrane – 1.5 lb; amniotic fluid – 2 lb; uterus – 2.5 lb; breasts – 3 lb; and increased blood volume – 2 to 4 lb; extravascular fluid and fat – 4 to 9 lb.
Option A: A gain of 12 to 22 lb is insufficient.
Option B: Whereas a weight gain of 15 to 25 lb is marginal.
Option D: A weight gain of 25 to 40 lb is considered excessive.
A pregnant client states that she “waddles” when she walks. The nurse’s explanation is based on which of the following as the cause?
-
Solution
Relaxation of the pelvic joints
During pregnancy, hormonal changes cause relaxation of the pelvic joints, resulting in the typical “waddling” gait.
Option A: Changes in posture are related to the growing fetus.
Option B: Pressure on the surrounding muscles causing discomfort is due to the growing uterus.
Option D: Weight gain has no effect on gait.
On which of the following areas would the nurse expect to observe chloasma?
-
Solution
Cheeks, forehead, and nose
Chloasma also called the mask of pregnancy, is an irregular hyperpigmented area found on the face. It is not seen on the breasts, areola, nipples, chest, neck, arms, legs, abdomen, or thighs.
Heartburn and flatulence, common in the second trimester, are most likely the result of which of the following?
-
Solution
Decreased gastric acidity
During the second trimester, the reduction in gastric acidity in conjunction with pressure from the growing uterus and smooth muscle relaxation, can cause heartburn and flatulence.
Option A: HCG levels increase in the first, not the second, trimester.
Option B: Decrease intestinal motility would most likely be the cause of constipation and bloating.
Option D: Estrogen levels decrease in the second trimester.
Which of the following urinary symptoms does the pregnant woman most frequently experience during the first trimester?
-
Solution
Frequency
Pressure and irritation of the bladder by the growing uterus during the first trimester is responsible for causing urinary frequency.
Options A, C, and D: Dysuria, incontinence, and burning are symptoms associated with urinary tract infections.
A couple who wants to conceive but has been unsuccessful during the last 2 years has undergone many diagnostic procedures. When discussing the situation with the nurse, one partner states, “We know several friends in our age group, and all of them have their own child already, Why can’t we have one?”. Which of the following would be the most appropriate nursing diagnosis for this couple?
-
Solution
Self-esteem disturbance related to infertility.
Based on the partner’s statement, the couple is verbalizing feelings of inadequacy and negative feelings about themselves and their capabilities. Thus, the nursing diagnosis of self-esteem disturbance is most appropriate.
Options A, B, and D: Fear, pain, and ineffective family coping also may be present but as secondary nursing diagnoses.
When assessing the adequacy of sperm for conception to occur, which of the following is the most useful criterion?
-
Solution
Sperm motility
Although all of the factors listed are important, sperm motility is the most significant criterion when assessing male infertility.
Options A, C, and D: Sperm count, sperm maturity, and semen volume are all significant, but they are not as significant sperm motility.