A client at 9-weeks gestation informs the nurse that she has reduced her alcohol intake but still consumes at least one alcoholic drink every evening before bedtime.
What action should the nurse take?
Praise the client for her actions and offer to discuss ways to decrease consumption even more.
Insist that the client stop all alcohol use and draw a blood alcohol level at each prenatal visit.
Notify child protective services of the client’s illicit drug use and probable child endangerment.
Refer the client to an outpatient alcohol abuse program for disulfiram therapy.
The Correct Answer is A
The correct answer is A. Praise the client for her actions and offer to discuss ways to decrease consumption even more.
Why? During pregnancy, any amount of alcohol poses a risk to the developing fetus, but abruptly shaming or forcing action may not be effective. The best approach is motivational interviewing, which involves acknowledging the client's reduction while encouraging further progress. A supportive conversation can help guide the client toward complete cessation of alcohol use.
Here’s why the other options are incorrect:
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B. Insist that the client stop all alcohol use and draw a blood alcohol level at each prenatal visit – While alcohol cessation is the goal, forcing the client without a supportive approach can lead to resistance. Routine blood alcohol testing is not standard unless substance dependence is suspected.
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C. Notify child protective services of the client’s illicit drug use and probable child endangerment – Alcohol is not classified as an illicit drug, and reporting at this stage would be premature unless clear evidence of abuse or harm to the fetus exists.
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D. Refer the client to an outpatient alcohol abuse program for disulfiram therapy – Disulfiram (Antabuse) is not recommended in pregnancy, as it may cause adverse effects. Instead, behavioral counseling and support groups are preferred interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
Age of the client is not a significant risk factor for postpartum hemorrhage. While age can influence overall health and pregnancy complications, it is not directly linked to an increased risk of postpartum hemorrhage. Therefore, the age of the client, in this case, does not increase the risk for postpartum hemorrhage.
Choice B rationale
The use of forceps during delivery can increase the risk of postpartum hemorrhage. Forceps delivery is an assisted delivery method which can cause trauma to the birth canal, leading to increased bleeding after delivery. In this case, the client had a forceps-assisted delivery, which could increase her risk for postpartum hemorrhage.
Choice C rationale
A 4th degree laceration is a severe tear that occurs during delivery, extending to the anal sphincter and rectal mucosa. This type of laceration can lead to significant blood loss and increase the risk of postpartum hemorrhage. In this case, the client had a 4th degree laceration, which increases her risk for postpartum hemorrhage.
Choice D rationale
A long labor duration can increase the risk of postpartum hemorrhage. Prolonged labor can lead to uterine atony, a condition where the uterus does not contract properly after delivery, leading to increased bleeding. In this case, the client was in labor for 25 hours, which could increase her risk for postpartum hemorrhage.
Correct Answer is B
Explanation
Choice A rationale
Immediately after delivery, the breasts of a new mother are not likely to remain the same as before delivery. Hormonal changes during pregnancy prepare the breasts for lactation, and these changes do not typically revert immediately after delivery.
Choice B rationale
On the first postpartum day, the breasts of a new mother are most likely to be filling and secreting colostrum. Colostrum is the first form of milk produced by the mammary glands, and it usually starts to be produced during pregnancy and continues during the early days of breastfeeding.
Choice C rationale
An immediate let-down response is not typically observed on the first postpartum day. The letdown reflex, which releases milk from the breast, usually becomes more pronounced after the first few days of breastfeeding.
Choice D rationale
While the breasts may become larger due to milk production, they are not typically very tender to touch on the first postpartum day. Tenderness may occur later, especially if complications like engorgement or mastitis develop.
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