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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Checking for bladder distention is a secondary nursing assessment to ensure the fetal head can descend properly. However, it does not address the patient's report of leaking fluid. While important for comfort and progress, it lacks the diagnostic priority required to differentiate between urine and amniotic fluid during labor admission.
Choice B reason: This is the priority action to confirm Spontaneous Rupture of Membranes (SROM). Nitrazine paper detects the alkaline pH of amniotic fluid, which turns the paper blue. According to NIH clinical guidelines, distinguishing amniotic fluid from acidic urine is essential to manage infection risks and plan appropriate obstetric interventions for labor.
Choice C reason: Testing for glucose is a metabolic screening tool used to monitor for gestational diabetes or renal threshold changes. It provides no clinical value in determining the status of the amniotic membranes. Following Maslow’s Hierarchy, ensuring physiological safety via membrane assessment takes precedence over routine metabolic urine screenings.
Choice D reason: Obtaining a culture is a diagnostic step for identifying pathogens like Group B Streptococcus, but it is not an initial assessment. Cultures require significant time for results and do not confirm rupture. Rapid bedside tests are the standard initial action to determine if the "bag of water" is broken.
Correct Answer is D
Explanation
This is based on the fact that HIV is a virus that attacks the body’s immune system and is spread through certain body fluids, including breast milk.Perinatal transmission can occur during pregnancy, birth, or breastfeeding.Treatment for HIV (antiretroviral therapy, or ART) substantially reduces the risk of perinatal transmission.
Choice A is wrong because sterilizing breast milk does not kill the HIV virus.
Choice B is wrong because colostrum can also contain the HIV virus and testing it is not feasible or reliable.
Choice C is wrong because breastfeeding may still pose a risk of HIV transmission even if the infant is determined to be HIV positive.
The current recommendation in the United States supports shared decision-making between mothers and their healthcare providers regarding infant feeding.Mothers who have questions about breastfeeding or who want to breastfeed should receive patient-centered, evidence-based counseling on infant feeding options, allowing for shared decision-making.
Counseling should begin before conception, or as early as possible in pregnancy and should be
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