A nurse in a clinic is caring for a client who is antepartum. The client expresses concern about preparing their preschooler for a new sibling.
Which of the following responses should the nurse make?

Avoid bringing your preschooler to prenatal visits.

Move your preschooler from their crib to a bed the day before the baby comes home.

Plan to spend individual time with your preschooler.

Ensure that your preschooler sees you holding the baby during the initial encounter.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Avoiding the preschooler's presence at prenatal visits can inadvertently promote feelings of exclusion and resentment, suggesting the new sibling is an unwelcome disruption. In contrast, involving the older child in the pregnancy experience, like listening to the fetal heartbeat, helps normalize the upcoming change and prepares them for the new family dynamic, fostering a positive adjustment. This inclusion is crucial for emotional security.

Choice B rationale

Making a significant change, such as moving the preschooler from a crib to a bed, immediately before or the day the new baby arrives, associates the loss of their comfortable sleeping arrangement with the sibling's arrival. This can be viewed as a punishment, increasing stress and anxiety and potentially fueling sibling rivalry and regression. Major changes should be made several weeks before the birth.

Choice C rationale

Planning and dedicating specific, high-quality individual time ("special time") with the preschooler reassures them of their continued importance and secures their parent-child bond. This counteracts the potential feeling of being displaced or replaced by the newborn, which is critical for maintaining their self-esteem and emotional well-being during the family transition.

Choice D rationale

Insisting the initial encounter be a visual of the parent holding the baby can immediately trigger jealousy and a sense of loss of parental attention, as the parent is focused elsewhere. Instead, the parent should greet the preschooler first with open arms and allow the child to approach the baby on their own terms, promoting a gentler, more positive introduction.

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

Explanations

Fetal presentation The fetus is in a left occiput anterior (LOA) vertex presentation, which is the most favorable position for vaginal birth. LOA allows for optimal alignment of the fetal head with the maternal pelvis, facilitating descent and rotation during labor. Malpresentations such as breech or transverse would be unfavorable, but vertex LOA is considered ideal. Therefore, this finding is favorable for vaginal delivery at 42 weeks gestation.

Cervical findings The cervix is described as closed and thick, which is unfavorable for vaginal birth. At 42 weeks, the cervix should ideally be effaced and dilated to allow for labor progression. A closed, thick cervix indicates that the cervix has not ripened, which may necessitate induction with cervical ripening agents such as prostaglandins or mechanical methods. Thus, this finding is not favorable for vaginal birth readiness.

Uterine contraction pattern The client reports only occasional mild uterine contractions, which is not favorable for vaginal birth at 42 weeks. Effective labor requires regular, strong contractions that cause progressive cervical dilation and effacement. Occasional mild contractions are insufficient to initiate or sustain active labor. At this post-term stage, the absence of an adequate contraction pattern suggests that induction may be required. Therefore, this finding is not favorable.

FHR The fetal heart rate is 150/min, which falls within the normal baseline range of 110 to 160 beats per minute. This indicates adequate fetal oxygenation and no evidence of tachycardia or bradycardia. A normal FHR is a favorable finding for vaginal birth, as it reflects reassuring fetal status. Continuous monitoring remains important, but this specific finding supports safe progression toward vaginal delivery.

A. Measure from the upper border of the symphysis pubis to the upper border of the fundus. B. Ensure that the client has a full bladder before taking the measurement. C. Lay the tape measure horizontally over the middle of the client's abdomen. D. Place the client in a left-lateral position to obtain the measurement.

Correct Answer is A

Explanation

Choice A rationale

Fundal height measurement is a simple clinical tool used to estimate gestational age and monitor fetal growth. The correct technique involves using a non-stretchable measuring tape to measure the distance in centimeters from the upper border of the symphysis pubis (a fixed bony landmark) to the highest point of the uterine fundus.

Choice B rationale

A full bladder can artificially elevate the uterine fundus, leading to an overestimation of the fundal height and an inaccurate assessment of fetal growth and gestational age. The nurse should instruct the client to empty their bladder before the measurement is taken to ensure the most reliable result.

Choice C rationale

The fundal height measurement is taken vertically, along the midline of the client's abdomen, from the symphysis pubis to the fundus. Measuring horizontally would not provide a clinically relevant or reproducible measure for assessing fetal growth or comparing against expected gestational age measurements.

Choice D rationale

Fundal height measurement should be performed with the client in the supine position with the knees slightly flexed. Placing the client in the left-lateral position is done to prevent supine hypotension syndrome (aorta-caval compression) but would make a standardized and accurate fundal height measurement impossible to obtain.

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A nurse in a clinic is caring for a client who is antepartum. The client expresses concern about preparing their preschooler for a new sibling. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a female client who is at 42 weeks of gestation in the prenatal clinic. Exhibits For each finding, click to specify if the finding is favorable or not favorable for vaginal birth at this stage of gestation. There must be at least 1 selection in every row.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

A nurse in a clinic is preparing to measure the fundal height of a client who is pregnant. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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A nurse in a clinic is caring for a client who is antepartum. The client expresses concern about preparing their preschooler for a new sibling.
Which of the following responses should the nurse make?