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A client who is at 8 weeks of gestation tells the nurse, 'I am not sure I am happy about being pregnant.' Which of the following responses should the nurse make?
- A. I will inform the provider that you are having these feelings.
- B. It is normal to have these feelings during the first few months of pregnancy.
- C. You should be happy that you are going to bring new life into the world.
- D. I am going to make an appointment with the counselor for you to discuss these thoughts.
Correct Answer: B
Rationale: Rationale for Correct Answer B: It is normal to have these feelings during the first few months of pregnancy.
1. Acknowledges client's emotions without judgment.
2. Validates the client's experience as common and normal.
3. Provides reassurance and support.
4. Encourages open communication.
Summary of Incorrect Choices:
A. Not necessary to escalate without client's consent.
C. Invalidates client's feelings and imposes expectations.
D. Implies assumption of severity and may be seen as intrusive.
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A healthcare professional is providing information to a group of clients who are pregnant about measures to relieve backache during pregnancy. Which of the following measures should the healthcare professional include? (Select all that apply)
- A. Avoid any lifting
- B. Perform Kegel exercises twice a day
- C. Perform the pelvic rock exercise every day
- D. Avoid standing for prolonged periods
Correct Answer: C
Rationale: The correct answer is C: Perform the pelvic rock exercise every day. This exercise helps strengthen the core muscles, which can alleviate backache during pregnancy. It also promotes flexibility in the lower back and pelvis.
Avoiding any lifting (A) is not a practical measure as some lifting may be necessary in daily activities. Performing Kegel exercises (B) strengthens pelvic floor muscles but does not directly address backache. Avoiding standing for prolonged periods (D) can help reduce backache but is not as effective as specific exercises targeting the back muscles like the pelvic rock exercise.
A newborn was transferred to the nursery 30 min after delivery. What should the nurse do first?
- A. Confirm the newborn's identification.
- B. Verify the newborn's identification.
- C. Administer vitamin K to the newborn.
- D. Determine obstetrical risk factors.
Correct Answer: B
Rationale: The correct answer is B because verifying the newborn's identification ensures the right baby is in the nursery. It is crucial for patient safety and prevents mix-ups. Confirming identification (choice A) is important but comes after verification. Administering vitamin K (choice C) is a necessary procedure but not the first priority. Determining obstetrical risk factors (choice D) is important but not as immediate as verifying identification. Thus, verifying the newborn's identification should be done first to prevent errors and ensure proper care.
When a client states, 'My water just broke,' what is the nurse's priority intervention?
- A. Perform Nitrazine testing.
- B. Assess the fluid.
- C. Check cervical dilation.
- D. Begin FHR monitoring.
Correct Answer: D
Rationale: The correct answer is D: Begin FHR monitoring. This is the priority intervention because assessing the fetal heart rate (FHR) helps determine the well-being of the baby after the water breaking. Monitoring the FHR can indicate if the baby is in distress and prompt further actions if needed. Performing Nitrazine testing (choice A) is used to confirm if the fluid is amniotic fluid, but FHR monitoring takes precedence. Assessing the fluid (choice B) is important but not as urgent as monitoring the FHR. Checking cervical dilation (choice C) is not the priority as ensuring the baby's well-being through FHR monitoring is crucial in this situation.
While assisting with the care of a client in active labor, a nurse observes clear fluid and a loop of pulsating umbilical cord outside the client's vagina. Which of the following actions should the nurse perform first?
- A. Place the client in the Trendelenburg position
- B. Apply finger pressure to the presenting part
- C. Administer oxygen at 10 L/min via a non-rebreather
- D. Call for assistance
Correct Answer: D
Rationale: The correct answer is D: Call for assistance. This is the first action the nurse should take in this emergency situation. Calling for help ensures that additional support and resources are available to manage the situation effectively. Placing the client in the Trendelenburg position (A) is not recommended as it can worsen the prolapsed cord. Applying finger pressure to the presenting part (B) can lead to further complications. Administering oxygen (C) may be necessary but is not the priority when a prolapsed cord is present.
A healthcare provider in an antepartum clinic is collecting data from a client who has a TORCH infection. Which of the following findings should the healthcare provider expect? (Select all that apply)
- A. Joint pain
- B. Malaise
- C. Rash
- D. Tender lymph nodes
Correct Answer: D
Rationale: The correct answer is D: Tender lymph nodes. In TORCH infections, which include Toxoplasmosis, Other (syphilis), Rubella, Cytomegalovirus, and Herpes simplex virus, tender lymph nodes are a common finding due to the body's immune response to the infection. Joint pain (choice A) is not typically associated with TORCH infections. Malaise (choice B) is a general feeling of discomfort and is not specific to TORCH infections. Rash (choice C) is also not a common finding in TORCH infections, making it an incorrect choice.