A client in preterm labor tells the nurse, “It’s okay that I am in labor.I’m not worried.
My sister’s baby was born this early, and he is doing great.” How should the nurse interpret this statement by the client? The client is:.

Trying to reassure herself concerning the present situation.

Coping as expected in this situation.

Anxious to see the new baby.

Able to use previously learned knowledge in a new situation.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A. The client is trying to reassure herself concerning the present situation. This is a common coping strategy for women who face the risk of preterm labor and delivery. The client may be experiencing fear, anxiety, or denial about the possible outcomes of her pregnancy.

Choice B is wrong because coping as expected in this situation implies that there is a normal or standard way of coping with preterm labor, which is not true. Different women may cope differently depending on their personal, social, and emotional factors.

Choice C is wrong because anxious to see the new baby does not reflect the client’s statement.

The client is not expressing excitement or eagerness about the birth, but rather a rationalization that everything will be okay despite the risks.

Choice D is wrong because able to use previously learned knowledge in a new situation does not apply to the client’s statement.

The client is not using her sister’s experience as a source of information or guidance, but rather as a way of minimizing or dismissing her own situation.

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Correct Answer is D

Explanation

The correct answer is choice D. Apply petrolatum to the patient’s perineum.This is because petrolatum can help soothe and protect the perineal area, which may be swollen, bruised, or have stitches after a vaginal delivery.Applying petrolatum can also prevent the pad from sticking to the wound and causing more pain.

Choice A is wrong because observing the patient for vaginal discharge of bright red blood is not a specific action for perineal care.Bright red blood may indicate postpartum hemorrhage, which requires immediate medical attention.

Choice B is wrong because assessing the patient’s vaginal tone is not a priority action for perineal care.Vaginal tone may be reduced after childbirth due to stretching of the pelvic floor muscles, but this can improve with time and exercises.

Choice C is wrong because massaging the patient’s perineum is not recommended for perineal care.Massaging the perineum may cause more trauma and discomfort to the area, especially if there are stitches or hemorrhoids.Massaging the fundus (the top of the uterus) may be done to help it contract and prevent bleeding, but this is different from massaging the perineum.

A. breast care teaching because she is predisposed to mastitis. B. frequent uterine fundal assessments because she is at risk for developing a prolapsed uterus. C. a strict toileting schedule because she is prone to developing a urinary tract infection. D. an “as needed” order for an analgesic because she is likely to have pain.

Correct Answer is B

Explanation

The correct answer is choice B. A multipara is a woman who has given birth more than once.

After delivery, the uterus contracts to return to its normal size and position.

However, in multiparas, the uterine muscles may be weaker and less able to contract effectively.

This can lead to a condition called uterine atony, where the uterus does not contract enough to prevent bleeding.

Uterine atony can also cause the uterus to descend into the vagina, which is called a prolapsed uterus.

Therefore, multiparas need frequent uterine fundal assessments to monitor the tone and position of the uterus and prevent complications.

Choice A is wrong because breast care teaching is important for all postpartum women, regardless of parity.

Mastitis is an inflammation of the breast tissue that can occur in any woman who is breastfeeding or not.

It is not more common in multiparas.

Choice C is wrong because a strict toileting schedule is not necessary for multiparas.

Urinary tract infections (UTIs) are caused by bacteria entering the urinary tract, usually from the urethra.

UTIs are not more common in multiparas, unless they have other risk factors such as catheterization, diabetes, or sexual activity.

Choice D is wrong because an “as needed” order for an analgesic may not be adequate for multiparas.

Pain after delivery can vary depending on the type and duration of labor, the size and position of the baby, and the use of anesthesia or episiotomy.

Multiparas may experience more pain due to stretching of the pelvic muscles and ligaments, or due to afterpains, which are contractions of the uterus that occur after delivery.

Therefore, multiparas may need regular doses of analgesics to manage their pain effectively.

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A client in preterm labor tells the nurse, “It’s okay that I am in labor.I’m not worried. My sister’s baby was born this early, and he is doing great.” How should the nurse interpret this statement by the client? The client is:.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During the postpartal admission assessment, the nurse notes that a patient’s perineum appears edematous and ecchymotic. Based on this finding, which action should the nurse take?

Correct Answer is D

Explanation

In planning the postpartum care of a multipara who had a normal pregnancy, labor, and delivery, which factor should be considered? The client needs to have:

Correct Answer is B

Explanation

A client treated for preterm labor is to be discharged to home. Which instruction should a nurse include in this client’s discharge plan? The client should:.

A patient states, “My water just broke.” The nurse verifies that her membranes have ruptured spontaneously. Which action should the nurse take next?

The nurse instructs a class of postpartum women on methods to avoid nipple soreness while breastfeeding. Which comment by a class participant indicates the need for further instruction?

When assessing a newborn, which is the best method for the nurse to use to elicit the Moro reflex?

A nurse is caring for a 16-year-old primigravida who is in the last month of an uncomplicated pregnancy. Which measure is most appropriate to include in the patient’s plan of care?

A client who is two weeks postpartum calls the office and tells a nurse, "l am having a small amount of brownish discharge from my vagina." Which response is appropriate for the nurse to make?

A client in preterm labor tells the nurse, “It’s okay that I am in labor.I’m not worried.
My sister’s baby was born this early, and he is doing great.” How should the nurse interpret this statement by the client? The client is:.