QUESTION: "A 20-year-old client, having missed one menstrual period, visits the prenatal clinic because she suspects that she is pregnant. Besides amenorrhea, the client tells the nurse that she has experienced nausea and vomiting, urinary frequency, and fatigue. The nurse determines that the client has been experiencing signs of pregnancy categorized as which of the following?"
CHOICES
( O ) a.) Presumptive.
( X ) b.) Probable.
( X ) c.) Positive.
( X ) d.) Predictive.
RATIONALE: Amenorrhea, urinary frequency, breast tenderness, nausea, vomiting, and fatigue are considered presumptive or subjective changes of pregnancy. Probable or objective signs of pregnancy include Goodell's sign (softening of the cervix), Chadwick's sign (discoloration of the mucous membranes of the cervix, vagina, and vulva), and Hegar's sign (softening of the isthmus of the uterus). Other probable signs include enlargement of the abdomen, uterine souffle, and Braxton-Hicks contractions. Positive or diagnostic signs of pregnancy include detection of the fetal heartbeat, detection of fetal movements by a trained examiner, and ultrasound identification of a fetus. Predictive is not a term used to denote signs and symptoms of pregnancy. NURSING PROCESS STEP: Analysis, nursing diagnosis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
