Health Promotion and Maintenance
57. A client, who is 18 years old, presents to a prenatal clinic because her menstrual period is 9 days late. She tells a nurse, "I'm sure I'm pregnant because my period is late and my breasts are tender." Which response by the nurse would be most appropriate?
. "A missed menstrual period and breast tenderness are probable signs of pregnancy."
. "A missed menstrual period and breast tenderness are presumptive signs of pregnancy."
. "A missed menstrual period and breast tenderness are positive signs of pregnancy."
. "A missed menstrual period and breast tenderness are negative signs of pregnancy."
Test-Taking Tip
Missed periods and breast tenderness are associated with pregnancy. Eliminate Answer 4, which states that they are negative signs of pregnancy. There are three positive signs of pregnancy that are objective and determined by the health-care provider; thus, Answer 3 can also be eliminated.
Content Area: Adult Health, Women's Health; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
Health Promotion and Maintenance
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Answer 1 is incorrect because probable signs of pregnancy are: Hegar's sign, ballottement, positive pregnancy test, and Goodell's sign, which are objective signs. Answer 2 is correct because presumptive signs of pregnancy are: amenorrhea, fatigue, breast tenderness and enlargement, morning sickness, and quickening, which are more subjective signs. Answer 3 is incorrect because the only positive signs of pregnancy are: auscultation of fetal heart tones, visualization of the fetus by ultrasound, and fetal movement felt by the health-care provider. Answer 4 is incorrect because amenorrhea and breast tenderness are presumptive signs of pregnancy, not negative signs.