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The client tells the nurse, “Most days, I am so happy I am pregnant, but other days, I am not sure that I am ready to have a baby.” Which is the most accurate response from the nurse?
- A. “This is such a happy time in your life. You need to be optimistic to feel happy.”
- B. “How does your spouse feel about the pregnancy? I hope he is happy about the baby.”
- C. “Feeling differently from day to day is normal. How do you feel today?”
- D. “Why do you feel this way? Is there something I can do to make it better for you?”
Correct Answer: C
Rationale: It is most therapeutic to acknowledge the client’s feelings and probe for more information on her thoughts and feelings about the pregnancy. Not all clients consider pregnancy a happy time in their lives, and the nurse should never tell the client how to feel. The nurse should not divert the client’s concerns away from self by bringing up the father’s adaptation to the pregnancy, even though paternal adaptation is related to maternal adaptation. The client may not be able to identify why she has the feelings she is experiencing or how the nurse can make her feel better. This response does not provide an avenue for further exploration of the client’s concerns.
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Which method best promotes client comfort during the pelvic examination?
- A. Have the client lift her head off the table.
- B. Have the client press her back into the examination table.
- C. Have the client tighten her buttocks.
- D. Tell the client to let her knees fall outward.
Correct Answer: D
Rationale: Letting the knees fall outward relaxes the pelvic muscles, reducing discomfort during the pelvic examination.
The laboring client just had a convulsion after being given regional anesthesia. Which interventions should the nurse implement? Select all that apply.
- A. Establish an airway.
- B. Position on her right side.
- C. Provide 100% oxygen.
- D. Administer diazepam.
- E. Page the anesthesiologist STAT.
Correct Answer: A,C,D,E
Rationale: The client experiencing a convulsion related to anesthesia should first have an airway established. The client experiencing a convulsion related to anesthesia should receive 100% oxygen so that the mother and fetus remain oxygenated. Small doses of diazepam or thiopental can be administered to stop the convulsions. The anesthesiologist should be STAT paged to provide assistance; the convulsion was initiated by the regional anesthetic. The client’s head should be turned to the side if vomiting occurs, but the client typically remains in a left lateral tilt position so an airway can be maintained. Positioning on the right side can cause aortocaval compression.
Which nursing instructions concerning exercise during pregnancy are accurate? Select all that apply.
- A. Avoid exercising during hot, humid weather.
- B. Avoid exercises involving bouncing or jumping movements.
- C. Drink plenty of fluids before and after exercising.
- D. Limit strenuous activity to no more than 60 minutes a session.
- E. Perform exercises only in the supine position.
- F. Limit exercising to once per week.
Correct Answer: A,B,C
Rationale: Exercising in hot weather risks overheating, bouncing movements may strain joints, and hydration is crucial. Supine exercises are avoided late in pregnancy.
The nurse identifies which factor as contributing to the client's stress?
- A. Stable employment
- B. Supportive partner
- C. Financial concerns
- D. Regular prenatal visits
Correct Answer: C
Rationale: Financial concerns are a common stressor during pregnancy, impacting the client's psychosocial well-being.
When one participant asks the nurse what can be done to relieve leg cramps while working, which instruction by the nurse is correct?
- A. Increase protein intake to five to six servings per day.
- B. Wear elastic stockings when at work.
- C. Point the toes frequently toward the head.
- D. Massage the leg when a cramp occurs.
Correct Answer: C
Rationale: Pointing toes toward the head (dorsiflexion) relieves leg cramps by stretching the calf muscles, unlike the other options.