A nurse is assessing a pregnant client for the presence of ballottement. To make this determination, the nurse does which of the following?

Appeared in: GMCH Chandigarh - 2019

Explanation

Ballottement is a probable sign of pregnancy, typically elicited between the 16th and 28th weeks of gestation.
The correct technique involves the examiner inserting two fingers into the vagina and applying a gentle, sharp upward tap on the cervix.
This maneuver causes the fetus, if it is unengaged and floating in the amniotic fluid, to rise and then rebound, creating a gentle tapping sensation on the examiner's fingers.
This rebound phenomenon is the key finding of a positive ballottement sign.

Option A: Auscultating for fetal heart sounds is a method to confirm fetal viability and is considered a positive sign of pregnancy, not the technique to elicit ballottement.
Option B: Assessing the cervix for compressibility or softening relates to Goodell's sign, which is another probable sign of pregnancy but is a different assessment from ballottement.
Option C: Palpating the abdomen for fetal movement, when felt by a trained examiner, is a positive sign of pregnancy. This is an external assessment, whereas ballottement is an internal (vaginal) examination technique.

Clinical Relevance

Nursing practice connection: Use the key finding related to Assessment technique for ballottement as a probable sign of pregnancy to guide bedside assessment, documentation, and the next nursing action.
Differentiating between presumptive, probable, and positive signs of pregnancy is a fundamental nursing skill for accurate gestational assessment and patient counseling.
While ballottement is a strong indicator, it is not definitive proof of pregnancy. It confirms a floating object in the uterus, which could, in rare cases, be a uterine polyp or tumor. Positive signs are required for a definitive diagnosis.
The absence of ballottement after 28 weeks can be a normal finding, often indicating that the fetal presenting part has descended and engaged into the pelvis, preparing for labor.

How to Approach the Question

First, identify the key term in the question stem, which is "ballottement."
Recall the definition and clinical procedure for eliciting this specific sign. Ballottement involves detecting a floating object within a fluid-filled cavity.
In the context of pregnancy, this means assessing for a floating fetus in the amniotic fluid via a vaginal examination.
Evaluate each option based on the correct procedure. Option A involves listening (auscultation), Option B involves feeling for tissue consistency (compressibility), and Option C involves external feeling (palpation).
Recognize that Option D, initiating a gentle upward tap on the cervix, is the precise maneuver used to cause the fetus to float up and rebound.
Eliminate the other options as they describe different, distinct assessments for other signs of pregnancy (fetal heart tones, Goodell's sign, or externally felt fetal movement).

Concept Tested & Keywords

Concept Tested: Assessment technique for ballottement as a probable sign of pregnancy.
Stem keywords: ballottement, pregnant client, assessing
Lead-in keywords: does which of the following
Clinical cues: Age/sex group narrows the expected diagnosis, intervention, or normal reference range.
Negative lead-in flag: false

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E6 Midwifery Obstetrics and Gynecology Nursing Sandeep Kaur p. 6-11

Practise the full GMCH Chandigarh - 2019

Attempt every question from this paper in a timed mock, then review the full solution for each one.