A nurse at a prenatal clinic is caring for a client who is in her first trimester of pregnancy. The client tells the nurse that she is upset because, although she and her husband planned this pregnancy, she has been having many doubts and second thoughts about the upcoming changes in her life.
Which of the following is an appropriate response by the nurse?
"Don't worry. You will be fine once the baby is born."
"Ambivalent feelings are quite common for women early in pregnancy."
"Perhaps you should see a counselor to discuss these feelings further."
"Have you spoken to your mother about these feelings?"
The Correct Answer is B
Choice A: This response is dismissive and does not validate the client's feelings. It may not address the client's concerns effectively.
Choice B: This response validates the client's feelings and reassures her that ambivalent feelings about pregnancy are common. It provides a supportive approach and normalizes her emotions.
Choice C: While counseling might be helpful for some clients, suggesting it immediately without further assessment of the client's needs may not be the most appropriate response at this stage.
Choice D: Encouraging the client to discuss her feelings with her mother may not be suitable, as the client might prefer professional support or may not have a positive relationship with her
mother. It is essential to avoid making assumptions about the client's support system and address her concerns empathetically.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is: c. The cervix is 1 cm dilated.
Choice A reason:
The presenting part is 1 cm above the ischial spines. This statement would be documented as -1 station. Fetal station is measured in centimeters relative to the ischial spines, with negative numbers indicating the presenting part is above the spines.
Choice B reason:
The cervix is effaced 1 cm. Effacement is measured in percentages, not centimeters. It refers to the thinning of the cervix, which progresses from 0% (not effaced) to 100% (fully effaced).
Choice C reason:
The cervix is 1 cm dilated. This means the cervix has opened 1 cm, which is a common measurement during early labor. Cervical dilation ranges from 0 cm (closed) to 10 cm (fully dilated).
Choice D reason:
The presenting part is 1 cm below the ischial spines. This would be documented as +1 station. Positive numbers indicate the presenting part is below the ischial spines, moving towards delivery.
Correct Answer is A
Explanation
A: Quickening, which refers to the sensation of the baby moving in the womb, is considered a presumptive sign of pregnancy. It is called "presumptive" because it is subjective and can be attributed to other causes, such as gas or gastrointestinal movements.
B: Positive signs of pregnancy are those that are attributed only to the presence of a fetus, such as fetal heartbeat or visualization on ultrasound. Feeling the baby move (quickening) is not specific enough to confirm pregnancy on its own.
C: Probable signs of pregnancy are more objective and can be detected by a healthcare provider, such as a positive pregnancy test or ballottement (rebounding of the fetus against the examiner's fingers). Feeling the baby move is not a probable sign as it is subjective and can be attributed to other factors.
D: "Potential sign of pregnancy" is not a recognized classification in pregnancy signs.
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