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.".

Answer and Explanation

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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Correct Answer is A

Explanation

Choice A rationale:

Painless, bright red vaginal bleeding at 36 weeks gestation is indicative of placenta previa. Placenta previa is a condition in which the placenta partially or completely covers the cervix, leading to bleeding as the cervix begins to efface and dilate. The bright red color of the blood is due to its fresh origin from the exposed placental vessels. This condition is painless because the bleeding occurs without uterine contractions.

Choice B rationale:

Preterm labor is not the correct answer in this scenario. Preterm labor refers to the onset of regular uterine contractions leading to cervical changes before 37 weeks of gestation. In this case, the key indicator is painless bleeding, which is not associated with uterine contractions.

Choice C rationale:

Threatened abortion is also not the correct answer. Threatened abortion is the term used when a pregnant woman experiences vaginal bleeding, but the cervix is closed, indicating that there is still a chance for the pregnancy to continue. However, the bleeding in placenta previa is unrelated to fetal viability and is specifically caused by the placental position.

Choice D rationale:

Abruptio placentae is not the correct answer either. Abruptio placentae, also known as placental abruption, is a condition where the placenta prematurely separates from the uterine wall before delivery. This can cause painful bleeding due to the blood being trapped between the placenta and uterine wall. In the given scenario, the bleeding is described as painless, which does not align with the characteristics of abruptio placentae.

A. Visual disturbances. B. Blood pressure. C. Respirations. D. Deep tendon reflexes. E. Weight. F. Fetal heart rate.

Correct Answer is ["A","B","F"]

Explanation

Choice A rationale:

The nurse should report visual disturbances to the provider. Visual disturbances in a pregnant client could indicate potential complications such as preeclampsia or eclampsia. These conditions are characterized by high blood pressure and can be harmful to both the mother and the fetus. Reporting visual disturbances promptly allows the provider to assess the situation and take appropriate actions to ensure the safety of the client and the baby.

Choice B rationale:

The nurse should also report blood pressure changes to the provider. The client's blood pressure has increased significantly from 179/99 mm Hg to 170/101 mm Hg over a short period. High blood pressure during pregnancy can be indicative of preeclampsia, a serious condition that requires close monitoring and management to prevent complications. Reporting the blood pressure changes promptly allows the provider to evaluate the situation and intervene as needed to safeguard the client's well-being.

Choice F rationale:

The nurse should report the fetal heart rate to the provider. Monitoring the fetal heart rate is crucial in prenatal care as it helps assess the well-being of the baby. Any abnormality in the fetal heart rate could indicate fetal distress or other complications. Promptly reporting any concerning changes in the fetal heart rate enables the provider to take appropriate measures to ensure the health and safety of the baby. The other choices (C, D, and E) are not the most critical findings in this scenario. While respiratory rate (C), deep tendon reflexes (D), and weight (E) are important aspects to monitor during pregnancy, they do not raise immediate concerns for potential complications like visual disturbances, blood pressure changes, and fetal heart rate abnormalities mentioned above. Nonetheless, they should still be documented and monitored regularly as part of routine prenatal care.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who is at 36 weeks gestation and has painless, bright red vaginal bleeding. The nurse recognizes this finding as an indication of which of the following conditions?

Correct Answer is A

Explanation

A nurse is caring for a client who is pregnant in a provider's office. Exhibits Which of the following findings should the nurse report to the provider? (Select all that apply)

Correct Answer is ["A","B","F"]

Explanation

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A nurse is assisting in the care of a client who is 36 weeks of gestation and reported to the clinic for a routine visit. Exhibits Which of the following findings should the nurse report to the provider? (Select all that apply)

A nurse is assisting with the monitoring of a client who is in the first stage of labor, with an external fetal monitor in place and IV fluids infusing. Which of the following factors will cause variable decelerations in the fetal heart rate?

A nurse is assisting with the care of a client who is in labor and has the urge to push. Which of the following instructions should the nurse give the client?

A nurse is assisting with the monitoring of a client who is in the first stage of labor, with an external fetal monitor in place and IV fluids infusing. Which of the following factors will cause variable decelerations in the fetal heart rate?

A nurse is assisting with the care of a client who is at 37 weeks of gestation and has placenta previa. Which of the following risks is the primary rationale the nurse should avoid performing a pelvic examination?