A nurse is assisting with the care of a client who is at 36 weeks of gestation and experienced preterm prelabor rupture of membranes. Which of the following actions should the nurse take?

Choice A reason:

If the parent states, "My child uses scissors to cut out the outline of an object,” this indicates fine motor skills development. While this is a positive milestone, it is not specific to the expected benchmarks of other preschoolers in this age group. The ability to cut out shapes with scissors varies widely among preschoolers.

Choice B reason:

"My child can copy triangle shapes onto paper.” This statement shows that the child can demonstrate some level of visual-motor coordination and fine motor skills. Copying shapes like triangles is a common milestone for many preschoolers at the age of 3 and is considered an expected benchmark.

Choice C reason:

If the parent says, "My child can ride a tricycle,” this indicates gross motor skills development. Riding a tricycle is also a milestone achieved by many preschoolers, but it may not be as specific to the expected benchmarks of this age group as choice B, which focuses on fine motor skills and visual-motor coordination.

Choice D reason:

If the parent mentions, "My child can throw a ball overhead,” this also points to gross motor skills development. While throwing a ball overhead is an impressive skill for a 3-year-old, it may not be as common or consistent among all preschoolers in this age group as the ability to copy triangle shapes onto paper (choice B).

Choice B reason: The nurse should ask the client if they have had thoughts about harming their infant. This is a crucial action because the client's statement suggests they may be experiencing feelings of inadequacy and self-doubt as a mother, which could potentially lead to more serious thoughts or actions. By directly asking about thoughts of harming the baby, the nurse can assess the client's mental and emotional state more thoroughly and determine if there is a risk of harm to the infant.

Choice A reason:

The nurse should advise the client that most new mothers experience these feelings. This response acknowledges the client's feelings of inadequacy and normalizes their experience, letting them know that it is common for new mothers to have doubts and insecurities. This validation can help the client feel less alone and more understood, promoting a therapeutic nurse-client relationship.

Choice C reason:

The nurse should explain to the client that they are experiencing the "baby blues.” This is a valid option because the client's statement indicates they may be experiencing mood swings, sadness, and emotional sensitivity, which are typical symptoms of the baby blues. Providing this information can help the client understand that these feelings are transient and often related to hormonal changes after childbirth.

Choice D reason:

Taking the client to the emergency department is not warranted based solely on the information provided. The client's statement does not indicate an immediate danger to themselves or their baby. However, if during the assessment (including choice B), the nurse identifies any signs of potential harm to the infant or the client, further action may be necessary, such as involving appropriate mental health professionals or support services.