The patient in the prenatal clinic tells the nurse that she is sure that she is pregnant because she has not had a menstrual cycle for three months, and her breasts are getting bigger. What response by the nurse is best?
1. "Lack of menses and breast enlargement are presumptive signs of pregnancy."
2. "The changes you are describing are definitely indicators that you are pregnant."
3. "Lack of menses can be caused by many things. We need to do a pregnancy test."
4. "Breast and menstrual changes are positive signs of pregnancy. Congratulations."
Correct Answer: 3
Rationale 1: Although this is true, amenorrhea and breast enlargement also can be caused by weight gain and other conditions. A pregnancy test is needed to determine whether the patient is pregnant.
Rationale 2: This statement is false because amenorrhea and breast enlargement are presumptive signs of pregnancy because they can be caused by other conditions.
Rationale 3: This is a true statement and addresses that these changes could be caused by things other than pregnancy.
Rationale 4: This statement is false because amenorrhea and breast enlargement are presumptive signs. It is too early to determine if congratulations are in order.
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