A nurse in the antepartum clinic is assessing a client's adaptation to pregnancy. The client states that she is, "happy one minute and crying the next." The nurse should interpret the client's statement as an indication of which of the following?

Emotional lability

Focusing phase

Cognitive restructuring

Couvade syndrome

Answer and Explanation

The Correct Answer is A

The correct answer is A. Emotional lability.

A. Emotional lability: Emotional lability refers to rapid and unpredictable changes in mood, with intense emotions shifting quickly from one extreme to another. It is a common aspect of the emotional adaptation to pregnancy and is often influenced by hormonal changes.

B. Focusing phase: The focusing phase is a concept related to the process of adapting to pregnancy. It involves the pregnant individual focusing on the reality of the pregnancy and incorporating the changes into their self-concept. While mood changes may occur during this phase, the client's statement more specifically reflects emotional lability.

C. Cognitive restructuring: Cognitive restructuring involves changing thought patterns to modify emotional responses. The client's statement does not necessarily indicate a deliberate process of changing thought patterns but rather describes the emotional swings often associated with pregnancy.

D. Couvade syndrome: Couvade syndrome refers to a phenomenon where a partner experiences symptoms that mimic pregnancy symptoms. It is not applicable in this context as the client is describing her own emotional experiences related to pregnancy.

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Correct Answer is B

Explanation

The correct answer is B. Turn the client onto her side.

A. Administering oxygen to the client is a reasonable intervention in the presence of late decelerations, but turning the client onto her side is the priority action to relieve potential compression of the vena cava and improve fetal oxygenation.

B. Turning the client onto her side is the correct first action.

Late decelerations are often associated with uteroplacental insufficiency. Changing the client's position, especially to the left lateral position, can help alleviate pressure on the vena cava, improving blood flow to the uterus and fetal oxygenation.

C. Increasing the client's IV fluid infusion rate may be considered, but it is not the first action to address late decelerations. Positioning changes should be initiated promptly.

D. Palpating the client's uterus is an assessment that may be done, but it is not the first action when late decelerations are observed. Positioning changes take precedence.

A. Contractions lasting longer than 90 seconds B. Contractions occurring every 3 to 5 min C. Client reports feeling contractions in lower back D. Contractions are strong in intensity

Correct Answer is A

Explanation

The correct answer is A. Contractions lasting longer than 90 seconds.

A. Contractions lasting longer than 90 seconds can be indicative of a prolonged contraction, which may affect uteroplacental perfusion and fetal oxygenation. This is a concern and should be reported to the provider.

B. Contractions occurring every 3 to 5 minutes are within the normal frequency range during the active phase of the first stage of labor.

C. The client reporting feeling contractions in the lower back is a common description of back labor, which may occur due to the position of the baby. It is not necessarily a cause for immediate concern unless it is associated with other issues.

D. Contractions being strong in intensity is expected during the active phase of labor. Strong contractions are necessary for cervical dilation and the progression of labor.

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A nurse in the antepartum clinic is assessing a client's adaptation to pregnancy. The client states that she is, "happy one minute and crying the next." The nurse should interpret the client's statement as an indication of which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in active labor when the client's membranes rupture. The fetal monitor tracing shows late decelerations Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is caring for a client who is in the active phase of the first stage of labor. When monitoring the uterine contractions, which of the following findings should the nurse report to the provider?

Correct Answer is A

Explanation

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