Nokea
Which intervention is most appropriate for a client experiencing low self-esteem during pregnancy?
- A. Encourage participation in a prenatal support group
- B. Prescribe antidepressants immediately
- C. Advise avoiding social interactions
- D. Ignore the issue as it is common
Correct Answer: A
Rationale: A prenatal support group fosters peer support and boosts self-esteem, addressing the client's emotional needs.
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Which position should the nurse recommend for early labor?
- A. Lying flat on the back
- B. Walking or standing
- C. Sitting upright
- D. Kneeling on all fours
Correct Answer: B
Rationale: Walking or standing in early labor promotes progress and comfort, unlike lying flat, which may slow labor.
Where can the nurse expect to palpate the fundus at this time?
- A. Just above the symphysis pubis
- B. Just below the xiphoid process
- C. Near the level of the umbilicus
- D. Just below the symphysis pubis
Correct Answer: C
Rationale: At 20 weeks' gestation, the fundus is typically palpated near the level of the umbilicus, reflecting uterine growth.
The postpartum client delivered a healthy newborn 36 hours previously. The nurse finds the client crying and asks what is wrong. The client replies, “Nothing, really. I’m not in pain or anything, but I just seem to cry a lot for no reason.” What should be the nurse’s first intervention?
- A. Call the client’s support person to come and sit with her.
- B. Remind her that she has a healthy baby and that she shouldn’t be crying.
- C. Contact the HCP to have the counselor come see the client.
- D. Ask the client to discuss her birth experience.
Correct Answer: D
Rationale: The client’s support person should be given information about postpartum blues before the client is discharged from the hospital. However, contacting that individual should not be the first intervention. Reminding the client that she has a healthy baby is a nontherapeutic communication technique that implies disapproval of the client’s actions. There is no need to notify the HCP, as postpartum blues is a common self-limiting postpartum occurrence. A key feature of postpartum blues is episodic tearfulness without an identifiable reason. Interventions for postpartum blues include allowing the client to relive her birth experience.
On the basis of the client's statement, what can the nurse conclude?
- A. The client is having twins.
- B. The client is between 14 and 18 weeks' gestation.
- C. The client is in the first trimester.
- D. The client's due date will be difficult to calculate.
Correct Answer: B
Rationale: Fetal movement in a multigravida is typically felt earlier, around 14-18 weeks, aligning with the client's report.
Interventions have been prescribed by the HCP for the client with decreased fetal movement at 35 weeks’ gestation. Place the prescribed interventions in the sequence that they should be performed by the nurse.
- A. Prepare for a nonstress test
- B. Prepare for a biophysical profile
- C. Palpate for fetal movement
- D. Apply and explain the external fetal monitor
Correct Answer: C,D,A,B
Rationale: Palpate for fetal movement should be performed first. Assessment should be first to verify fetal movement. Apply and explain the external fetal monitor should be next. The fetus should be monitored for heart rate changes. Prepare for an NST. The NST is performed to determine fetal well-being. Prepare for a biophysical profile (BPP). The BPP is an assessment of five fetal biophysical variables: FHR acceleration, fetal breathing, fetal movements, fetal tone, and amniotic fluid volume. The first criterion is assessed with the NST. The other variables are assessed by ultrasound scanning.