A nurse in a prenatal clinic is caring for a client who reports that her menstrual period is 2 weeks late. The client appears anxious and asks the nurse if she is pregnant. Which of the following responses should the nurse make?
"You can miss your period for several other reasons. Describe your typical menstrual cycle
"If you have been sexually active and haven't used protection it is likely that you are pregnant
"Let's check to see if you have any other signs of pregnancy. Have you noticed any abdominal enlargement yet?
"Because you have missed your period, you should try taking a home pregnancy test before you start worrying
The Correct Answer is A
Choice A Reason:
"You can miss your period for several other reasons. Describe your typical menstrual cycle." This response acknowledges that a missed period can result from various factors other than pregnancy, such as stress, changes in weight, hormonal fluctuations, or certain medical conditions. Understanding the client's typical menstrual cycle can help the nurse gather more information about potential reasons for the late period.
Choice B Reason:
"If you have been sexually active and haven't used protection, it is likely that you are pregnant. “This response assumes pregnancy without exploring other possibilities or the client's individual situation.
Choice C Reason:
"Let's check to see if you have any other signs of pregnancy. Have you noticed any abdominal enlargement yet?" While considering other signs of pregnancy is reasonable, focusing on abdominal enlargement may not be the most accurate early indicator, and it's essential to explore a broader range of symptoms.
Choice D Reason:
"Because you have missed your period, you should try taking a home pregnancy test before you start worrying. "While suggesting a home pregnancy test is reasonable, it may be more beneficial to gather additional information about the client's menstrual cycle and potential symptoms before jumping directly to a test.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is B. Massage the client's back.
A. Turning the client onto her left side may be a comfort measure, but it is not specifically associated with the gate control theory of pain. It may help improve blood flow and relieve pressure but does not directly engage the gate control mechanism.
B. Massage the client's back is consistent with the gate control theory of pain.
According to the gate control theory, non-painful input (such as massage) can close the "gate" to painful input, reducing the perception of pain. Massage stimulates large-diameter nerve fibers, which can inhibit the transmission of painful signals.
C. Encouraging the client to rest between contractions is a general comfort measure but is not directly related to the gate control theory of pain.
D. Administering prescribed analgesic medication is a pharmacological approach to pain management and is not specifically associated with the gate control theory. Medications can act on pain receptors but do not engage the gate control mechanism.
Correct Answer is A
Explanation
The correct answer is A. Variable decelerations are due to umbilical cord compression.
A. Variable decelerations are often associated with umbilical cord compression. This compression can occur when the umbilical cord is briefly compressed or squeezed, leading to transient decreases in fetal heart rate.
B. Variable decelerations are not typically a result of the administration of IV narcotic analgesics. They are more commonly associated with cord compression or other factors affecting fetal oxygenation.
C. Variable decelerations are not generally caused by uteroplacental insufficiency. Uteroplacental insufficiency is more commonly associated with late decelerations.
D. Variable decelerations are not primarily related to fetal head compression. While head compression can cause certain types of decelerations, variable decelerations are specifically associated with umbilical cord compression.
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