A nurse is assisting with the care of a client who is at 32 weeks of gestation and in labor. The client asks the nurse, "Will my baby be okay?”. Which of the following responses should the nurse make?
"We have a neonatal unit here equipped to handle emergencies.".
"You must be feeling very scared.".
"Everyone worries about their baby while they are in labor.".
"You are far enough along that your baby will be just fine.".
The Correct Answer is B
The correct answer is choice B: “You must be feeling very scared.” This response is an example of therapeutic communication, where the nurse acknowledges the client’s feelings and provides emotional support without making assumptions or giving false reassurances.
Choice A rationale: While it’s true that the presence of a neonatal unit equipped to handle emergencies is reassuring, this response does not address the client’s immediate emotional needs or fears. It’s important for the nurse to recognize and validate the client’s feelings rather than focusing solely on the facilities available.
Choice B rationale: This choice demonstrates empathy and understanding. It allows the client to express their feelings and concerns, which is a crucial aspect of providing emotional support during labor. By acknowledging the client’s potential fear, the nurse opens the door for further communication and support.
Choice C rationale: This response minimizes the client’s individual feelings by suggesting that everyone has the same worries. It can make the client feel that their concerns are not unique or taken seriously, which is not conducive to establishing trust or providing individualized care.
Choice D rationale: This choice provides false reassurance. At 32 weeks of gestation, while the prognosis for the baby is generally good, there are still risks associated with preterm birth. It’s important not to make definitive statements about outcomes that cannot be guaranteed.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Helping the client to the bathroom to empty her bladder is not the appropriate response in this situation. The client's sudden urge to push indicates that she is in the second stage of labour, which is the pushing phase. The cervix is already dilated at 7 cm, and the fetus is at 1+ station, indicating that delivery is imminent. Emptying the bladder at this point is not a priority and may delay necessary actions.
Choice B rationale:
Assisting the client into a comfortable position is also not the appropriate response. The client's urge to push suggests that she is in the active stage of labor, and her cervix is already 7 cm dilated. Encouraging a comfortable position might not be suitable since the focus should be on monitoring the progress of labor and preparing for delivery.
Choice C rationale:
Having the client pant during the next few contractions is not the correct response either. Panting is typically recommended during the transition phase of labor to prevent rapid pushing and potential damage to the perineum. However, in this scenario, the client is already fully dilated, and the fetus is at 1+ station, indicating that the second stage of labour has commenced. Panting is not necessary at this point.
Choice D rationale:
The appropriate nursing response is to assess the perineum for signs of crowning. The sudden urge to push indicates that the baby is descending through the birth canal and may be close to crowning, which is when the baby's head becomes visible at the vaginal opening. By assessing for crowning, the nurse can determine if delivery is imminent and notify the healthcare provider for further actions and preparation for the baby's birth.
Correct Answer is C
Explanation
Choice A reason:
Blood pressure. The nurse does not need to report the blood pressure because it is not mentioned in the given information that there is any abnormality or concern related to the client's blood pressure. Therefore, it is not a priority finding to report.
Choice B reason:
Cerebral manifestations. There is no mention of cerebral manifestations in the nurse's notes. Since there are no reported neurological symptoms or abnormalities, the nurse does not need to report cerebral manifestations to the provider.
Choice C reason:
Fetal heart rate. The nurse should report the fetal heart rate to the provider because it is an essential parameter to monitor during prenatal care. A normal fetal heart rate ranges from 110 to 160 beats per minute, and in this case, the fetal heart rate is 158/min, which falls within the normal range. However, it is still necessary to inform the provider about this vital sign for documentation and reassurance.
Choice D reason:
Respiratory rate. The respiratory rate is not mentioned in the nurse's notes, and there are no indications of any respiratory issues or concerns. Therefore, it is not necessary to report the respiratory rate to the provider based on the information provided.
Choice E reason:
Deep tendon reflexes. The nurse notes that the patellar reflex is 3+ and clonus is negative. These findings are within the normal range and do not require reporting to the provider.
Choice F reason:
Gastrointestinal assessment findings. The nurse's notes do not mention any abnormal gastrointestinal assessment findings. Since there are no indications of gastrointestinal issues, the nurse does not need to report any gastrointestinal findings to the provider.
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