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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
A fetal heart rate of 100/min for a 10-minute period is considered within the normal range. The normal fetal heart rate can range from 110 to 160 beats per minute, and a rate of 100 is not concerning.
Choice B rationale:
The resting period of a contraction refers to the time between contractions when the uterus is relaxed. A resting period of 35 seconds is also considered normal. In labor, the resting period between contractions allows the placenta to receive oxygen and nutrients, and 35 seconds is a rationaleable duration.
Choice C rationale:
A contraction lasting 85 seconds is abnormal and should be reported to the provider. Normally, contractions last around 60-90 seconds, but an 85-second contraction may indicate uterine hyperactivity or other issues that could potentially affect the well-being of both the mother and the baby.
Choice D rationale:
Having four contractions in a 10-minute period is considered normal during labor. In fact, an average pattern includes 3-5 contractions within a 10-minute window, so this finding is not a cause for concern.
Correct Answer is D
Explanation
The correct answer is choice d. Vastus lateralis.
Choice A rationale:
The deltoid muscle is not typically used for newborn injections because it is too small and underdeveloped, making it an inappropriate site for intramuscular injections in this age group.
Choice B rationale:
The dorsogluteal muscle is also not recommended for newborns due to the risk of injury to the sciatic nerve and the muscle’s underdevelopment.
Choice C rationale:
The ventrogluteal muscle, while a good site for older children and adults, is not commonly used for newborns because it is not as easily accessible and developed as the vastus lateralis.
Choice D rationale:
The vastus lateralis muscle, located on the anterolateral aspect of the thigh, is the preferred site for intramuscular injections in newborns. It is well-developed and provides a large muscle mass, making it the safest and most effective site for administering vitamin K.
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