a client tells the nurse that she thinks shes pregnant which signs or symptoms provide the best indication that the client is pregnant
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Nursing Elites

HESI LPN

HESI Maternal Newborn

1. A client tells the nurse that she thinks she's pregnant. Which signs or symptoms provide the best indication that the client is pregnant?

Correct answer: D

Rationale: Hegar's sign, which is a softening of the lower uterine segment, is considered a probable sign of pregnancy as it indicates changes in the cervix and uterus that occur during pregnancy. Amenorrhea, the absence of menstruation, is a common early sign of pregnancy but can also be due to other factors. Morning sickness, nausea and vomiting, can be a sign of early pregnancy but is not as specific as Hegar's sign. Breast tenderness is a common symptom in early pregnancy due to hormonal changes, but it is not as definitive as Hegar's sign in indicating pregnancy.

2. A client is receiving oxytocin by continuous IV infusion for labor induction. Which of the following interventions should the nurse include in the plan?

Correct answer: A

Rationale: The correct answer is to increase the infusion rate every 30 to 60 minutes. This approach allows for the careful monitoring and adjustment of oxytocin administration during labor induction. Choice B is incorrect because maintaining the client in a supine position can decrease blood flow to the placenta and compromise fetal oxygenation. Choice C is incorrect as titrating the infusion rate by 4 milliunits/min is not a standard practice for oxytocin administration. Choice D is incorrect as limiting IV intake to 4 L per 24 hours is not specifically related to the administration of oxytocin for labor induction.

3. Polygenic traits are those that are:

Correct answer: D

Rationale: Polygenic traits, such as height and skin color, are determined by several pairs of genes working together. These traits are influenced by the combined effects of multiple genes across the genome, rather than being controlled by a single gene pair. Choices A, B, and C are incorrect because polygenic traits are not specifically developed during adolescence, transmitted by the mother, or uncommon in humans. Understanding polygenic traits is essential in genetics as they demonstrate the complexity of genetic inheritance and the influence of multiple genes on a single trait.

4. A newborn's head circumference is 12 inches (30.5 cm) and his chest measurement is 13 inches (33 cm). The nurse notes that this infant has no molding, and it was a breech presentation delivered by cesarean section. What action should the nurse take based on this data?

Correct answer: D

Rationale: Head and chest circumference measurements are within normal limits for a newborn, especially for those delivered by cesarean section, so no immediate action is required beyond documentation.

5. Following a traumatic delivery, an infant receives an initial Apgar score of 3. Which intervention is most important for the nurse to implement?

Correct answer: B

Rationale: In a situation where an infant receives a low Apgar score of 3 following a traumatic delivery, the most crucial intervention for the nurse to implement is to continue resuscitative efforts. A low Apgar score indicates that the newborn is in distress and requires immediate medical attention to support breathing, heart rate, muscle tone, reflex irritability, and color. Continuing resuscitative efforts is essential to provide life-saving interventions promptly. Paging the pediatrician may cause a delay in crucial interventions, repeating the Apgar assessment in 5 minutes is not appropriate as immediate action is needed to stabilize the infant, and informing parents should not take precedence over providing immediate medical care to the newborn.

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