A couple who has had difficulty conceiving confides in the nurse at the infertility clinic that they feel overwhelmed with the decisions that face them. Which of the following nursing strategies would be most appropriate and therapeutic?
Select one:

Provide compassionate and accurate information throughout the process and support them to make their own decisions.

Inquire about the names they have chosen for their baby to get their mind oﬀ their stress.

Express sympathy and provide directive advice to the couple about what they should do.

Refer them to a marriage counselor in the same building to help them with the decisions.

Answer and Explanation

The Correct Answer is A

Choice A Reason: Provide compassionate and accurate information throughout the process and support them to make their own decisions. This is a therapeutic strategy that demonstrates empathy, honesty, and advocacy for the couple. It also helps them understand their options, risks, benefits, and alternatives, and encourages them to participate in their care.

Choice B Reason: Inquire about the names they have chosen for their baby to get their mind oﬀ their stress. This is a non-therapeutic strategy that avoids addressing the couple's concerns, minimizes their feelings, and may create false hope or unrealistic expectations.

Choice C Reason: Express sympathy and provide directive advice to the couple about what they should do. This is a non-therapeutic strategy that shows pity, imposes personal values, and undermines the couple's self-determination.

Choice D Reason: Refer them to a marriage counselor in the same building to help them with the decisions. This is a non-therapeutic strategy that implies that the couple has marital problems, shifts responsibility, and may create resentment or resistance.

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Correct Answer is A

Explanation

Choice A Reason: Inspecting the placenta after delivery for intactness. This is because inspecting the placenta after delivery for intactness is a nursing intervention that can prevent late postpartum hemorrhage, which is excessive bleeding from the uterus or genital tract that occurs more than 24 hours but less than 12 weeks after delivery. Late postpartum hemorrhage can be caused by retained placental fragments, subinvolution of the uterus, infection, or coagulation disorders. Inspecting the placenta after delivery for intactness can help identify and remove any retained placental fragments that may interfere with uterine contraction and involution, which are essential for hemostasis.

Choice B Reason: Manually removing the placenta at delivery. This is an incorrect answer that indicates an inappropriate and risky intervention that can cause late postpartum hemorrhage. Manually removing the placenta at delivery is a procedure that involves inserting a hand into the uterus and detaching the placenta from the uterine wall. Manually removing the placenta at delivery is indicated only for a retained or adherent placenta that does not separate spontaneously or with gentle traction within 30 minutes after delivery. Manually removing the placenta at delivery can cause trauma, infection, or incomplete removal of the placenta, which can increase the risk of late postpartum hemorrhage.

Choice C Reason: Administering broad-spectrum antibiotics prophylactically. This is an incorrect answer that suggests an unnecessary and ineﬀective intervention that can prevent late postpartum hemorrhage. Administering broad- spectrum antibiotics prophylactically is a pharmacological intervention that involves giving antibiotics to prevent or treat infection. Administering broad-spectrum antibiotics prophylactically is indicated for women with risk factors or signs of infection during or after delivery, such as prolonged rupture of membranes, chorioamnionitis, fever, or foul- smelling lochia. Administering broad-spectrum antibiotics prophylactically may reduce the risk of infection-related late postpartum hemorrhage, but it does not address other causes of late postpartum hemorrhage such as retained placental fragments or subinvolution of the uterus.

Choice D Reason: Applying traction on the umbilical cord to speed up separation of the placenta. This is an incorrect answer that refers to a diﬀerent intervention that can prevent early postpartum hemorrhage, not late postpartum hemorrhage. Applying traction on the umbilical cord to speed up separation of the placenta is a technique that involves pulling on the umbilical cord while applying counter pressure on the uterus to facilitate placental expulsion. Applying traction on the umbilical cord to speed up separation of the placenta is indicated for active management of the third stage of labor, which can prevent early postpartum hemorrhage, which is excessive bleeding from the uterus or genital tract that occurs within 24 hours after delivery. Early postpartum hemorrhage can be caused by uterine atony, retained placenta, lacerations, or coagulation disorders.

A. Obtain a bilirubin level. B. Place a pulse oximeter on the newborn. C. Obtain a blood glucose level. D. Take the newborn's vital signs.

Correct Answer is C

Explanation

Choice A Reason: Obtain a bilirubin level. This is an incorrect answer that indicates an irrelevant and unnecessary nursing action for a newborn with tremors or jiteriness. Obtaining a bilirubin level is a nursing action that is indicated for a newborn with jaundice (yellowish discoloration of the skin and mucous membranes), which can occur due to increased bilirubin production or decreased bilirubin excretion. Jaundice does not cause tremors or jiteriness in newborns.

Choice B Reason: Place a pulse oximeter on the newborn. This is an incorrect answer that suggests an inappropriate and insufficient nursing action for a newborn with tremors or jiteriness. Placing a pulse oximeter on the newborn is a nursing action that measures oxygen saturation and heart rate, which can indicate hypoxia (low oxygen level) or distress in newborns. Hypoxia can cause tremors or jiteriness in newborns, but it is not the only or most likely cause. Placing a pulse oximeter on the newborn does not provide enough information to diagnose or treat hypoglycemia.

Choice C Reason: Obtain a blood glucose level. This is because tremors or jiteriness are common signs of hypoglycemia (low blood glucose) in newborns, which can occur due to various factors such as prematurity, maternal diabetes, infection, or cold stress. Hypoglycemia can cause neurological damage or death if not treated promptly and eﬀectively. Obtaining a blood glucose level is a nursing action that has the highest priority for a newborn with tremors or jiteriness, as it can confirm the diagnosis and guide the treatment.

Choice D Reason: Take the newborn's vital signs. This is an incorrect answer that implies an inadequate and delayed nursing action for a newborn with tremors or jiteriness. Taking the newborn's vital signs is a nursing action that monitors temperature, pulse, respiration, and blood pressure, which can indicate general health status and stability in newborns. Taking the newborn's vital signs may reveal signs of hypoglycemia, such as hypothermia, tachycardia, tachypnea, or hypotension, but it is not a specific or definitive test for hypoglycemia. Taking the newborn's vital signs may also waste valuable time that could be used to obtain a blood glucose level and initiate treatment.

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A couple who has had difficulty conceiving confides in the nurse at the infertility clinic that they feel overwhelmed with the decisions that face them. Which of the following nursing strategies would be most appropriate and therapeutic? Select one:

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Naxlex Comprehensive Predictor Exams

Which of the following would be essential to implement to prevent late postpartum hemorrhage? Select one:

Correct Answer is A

Explanation

The Mother-Baby nurse is caring for a two hour old newborn who is 36 4/7 weeks gestation. The nurse assesses that the newborn is experiencing tremors (jiteriness). What nursing action has the highest priority? Select one:

Correct Answer is C

Explanation

Which of the following would the nurse include in the plan of care for a newborn receiving phototherapy? Select one:

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The client at 42 weeks' pregnancy is admited for induction of her labor. Which statement indicates that she understands the Reasons for the induction? Select one:

A couple who has had difficulty conceiving confides in the nurse at the infertility clinic that they feel overwhelmed with the decisions that face them. Which of the following nursing strategies would be most appropriate and therapeutic? Select one:

An nurse is counseling a new mother about the immunologic properties of breast milk. The nurse emphasizes that breast milk is the main source of which specific immunoglobulin? Select one:

A client has been diagnosed with postpartum psychosis. Which of the following actions should the nurse take? Select one:

A couple who has had difficulty conceiving confides in the nurse at the infertility clinic that they feel overwhelmed with the decisions that face them. Which of the following nursing strategies would be most appropriate and therapeutic?
Select one: