A nurse is caring for a client who is in preterm labor at 32 weeks of gestation. The client asks the nurse. "Will my baby be okay?" Which of the following responses should the nurse offer?

"We have a neonatal unit here that's equipped to handle emergencies."

"Your pregnancy is advanced so your baby should be fine.

"You must be feeling scared and powerless.

"Everyone worries about her baby when she's in labor."

Answer and Explanation

The Correct Answer is D

Answer: C. "You must be feeling scared and powerless."

Rationale:

A) "We have a neonatal unit here that's equipped to handle emergencies.": While this statement provides some reassurance about the availability of care, it may come across as dismissive of the client's feelings. It does not directly address the emotional aspect of the client's concern, which is crucial during this stressful time.

B) "Your pregnancy is advanced so your baby should be fine.": This response may offer false reassurance. Although 32 weeks is relatively advanced in preterm terms, it does not guarantee that the baby will be fine, and the client's feelings and concerns are not acknowledged.

C) "You must be feeling scared and powerless.": This response is empathetic and validates the client's emotions. It opens up a dialogue for the client to express her feelings, allowing the nurse to provide emotional support and address her concerns more effectively.

D) "Everyone worries about her baby when she's in labor.": While this statement acknowledges that worry is common, it may downplay the client's specific fears. It does not provide the personalized support she needs or validate her unique situation.

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Correct Answer is D

Explanation

A. Contractions lasting longer than 90 seconds: Prolonged contractions lasting longer than 90 seconds may indicate uterine hyperstimulation, which can compromise fetal oxygenation and lead to fetal distress. This finding should be reported to the provider promptly for further evaluation and management.

B. Client reports feeling contractions in the lower back: This is a common sensation during labor and may not necessarily indicate a complication. However, if associated with other signs of fetal distress, it should be reported.

C. Contractions occurring every 3 to 5 minutes: This frequency is within the normal range for the active phase of labor and does not necessarily indicate a problem. However, it is essential to consider the duration and intensity of contractions along with this frequency.

D. Contractions are strong in intensity: While strong contractions are typical during the active phase of labor, the intensity alone may not be a cause for concern unless they are associated with uterine hyperstimulation.

A. Turn the client onto her side. B. Increase the client's IV fluid infusion rate. C. Palpate the client's uterus. D. Administer oxygen to the client.

Correct Answer is A

Explanation

A) Turn the client onto her side: Late decelerations indicate uteroplacental insufficiency, which can be caused by reduced blood flow to the placenta. Turning the client onto her side, particularly the left side, can help improve placental blood flow by reducing pressure on the vena cava and increasing blood flow to the uterus and placenta. This action is a priority as it aims to improve fetal oxygenation.
B) Increase the client's IV fluid infusion rate: While maintaining adequate hydration is important during labor, increasing IV fluid infusion rate may not immediately address the issue of late decelerations. It is essential to improve fetal oxygenation first by repositioning the client.
C) Palpate the client's uterus: Palpating the client's uterus may provide information about uterine activity and contraction pattern, but it does not directly address the immediate concern of late decelerations.
D) Administer oxygen to the client: Administering oxygen is an appropriate intervention for fetal distress, but turning the client onto her side is the priority action to improve blood flow to the placenta and fetal oxygenation.

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A nurse is caring for a client who is in preterm labor at 32 weeks of gestation. The client asks the nurse. "Will my baby be okay?" Which of the following responses should the nurse offer?

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Naxlex Comprehensive Predictor Exams

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 D

Explanation

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Correct Answer is A

Explanation

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