A nurse is caring for a couple who experienced a fetal death at 37 weeks of gestation. Which of the following responses by the nurse is therapeutic?
"I think you should call your minister. He can help comfort you."
"It must be very difficult for you both. I will be available if you need anything."
"You are both young and can have other children."
"Did you have any complications during your pregnancy?"
The Correct Answer is B
Choice A rationale: This response assumes that the couple's religious beliefs are relevant to them, which may not be the case. It is not appropriate for the nurse to suggest involving their minister without knowing their preferences or beliefs.
Choice B rationale: This response acknowledges the couple's emotional experience and shows empathy toward their grief. It offers support and reassurance that the nurse will be available to help them through this difficult time.
Choice C rationale: While this statement may be factually true, it is not empathetic or supportive of the couple's current emotional state. It may come across as dismissive of their feelings and minimize their grief.
Choice D rationale: While gathering information about the pregnancy is essential for the medical record, this question does not address the couple's emotional needs. It is more appropriate to focus on offering emotional support and assistance rather than immediately delving into clinical details.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: A positive contraction stress test warrants immediate attention and evaluation. Waiting for 24 hours to repeat the test could delay necessary interventions in case of fetal distress.
Choice B rationale: A positive contraction stress test indicates that there are late decelerations in the baby's heart rate during contractions, which may suggest fetal distress. In such cases, it is essential to admit the client to the hospital for further evaluation, monitoring, and appropriate management.
Choice C rationale: Checking the client's cervix for dilation is not the most appropriate action in response to a positive contraction stress test. Fetal well-being and assessment take priority in this situation.
Choice D rationale: A positive contraction stress test requires further action and should not be considered a routine finding. Proper management and evaluation are necessary when the test results are positive.
Correct Answer is C
Explanation
Choice A rationale: RhoGAM is not given solely based on blood loss. It is administered to prevent Rh isoimmunization, which is unrelated to the amount of blood loss.
Choice B rationale: If the client has previously given birth to an Rh-negative infant, she is already sensitized and would not require RhoGAM for this current ectopic pregnancy.
Choice C rationale: Rho(D) Immune globulin (RhoGAM) is given to Rh-negative individuals to prevent the development of Rh isoimmunization, which could occur if the client is exposed to Rh-positive blood. In the case of an ectopic pregnancy, there may be a possibility of fetal blood mixing with the mother's bloodstream, which could lead to sensitization in an Rh-negative individual.
Choice D rationale: The desire to conceive again does not dictate the need for RhoGAM. It is solely based on the client's Rh factor status and the potential for sensitization during the ectopic pregnancy.
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