43. A 23-year-old client has missed two menstrual periods and decides to visit a prenatal clinic to see if she is pregnant. Besides amenorrhea, the client tells a nurse that she has experienced breast tenderness, nausea and vomiting, urinary frequency, and fatigue. The nurse determines that the client has been experiencing symptoms of pregnancy that are classified as:
Test-Taking Tip
Presumptive signs are the earliest signs and symptoms of pregnancy, but some symptoms can be explained by other conditions. Probable signs are usually signs of pregnancy, but may be false or explained by other conditions. Positive signs are those that cannot be explained by any other condition than pregnancy.
Content Area: Maternity, Antepartum; Integrated Process: Nursing Process, Analysis; Cognitive Level: Application; Client Need/Subneed: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
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Answer 1 is incorrect because there are no "predictive" signs of pregnancy; it is a madeup term. Answer 2 is correct because presumptive signs/symptoms of pregnancy include: absent menstrual periods (amenorrhea), nausea and/or vomiting ("morning sickness"), unexplained fatigue, the frequent need to urinate, breast tenderness and changes, excessive salivation (ptyalism), skin changes, and a sensation of movement in the abdomen (quickening). Answer 3 is incorrect because probable signs of pregnancy include: positive pregnancy test (presence of human chorionic gonadotropin detected by blood or urine test); softening of cervix at 6 to 8 weeks (Goodell's sign); bluish coloration of cervix, vagina, and vulva at 6 to 8 weeks (Chadwick's sign); enlarged abdomen; Braxton Hicks contractions; and passive movement of the fetus during an examination (ballottement). Answer 4 is incorrect because positive signs of pregnancy include: fetal heart sounds heard by Doptone or Doppler, fetus visible on ultrasound, fetal movements felt by caregiver, and fetus visible on x-ray, magnetic resonance imaging (MRI) or other diagnostic imaging device. (Note: X-ray, MRI and other imaging devices are not recommended during pregnancy.)
