A nurse is caring for a female client scheduled to have a pelvic exam. The client tells the nurse, “I’m really nervous.
I’ve never had a pelvic exam before.” Which of the following is an appropriate therapeutic response by the nurse?
A pelvic exam is required if you want birth control pills
Don't worry, I will stay in there with you for the exam
All you need to do is relax during the exam
Tell me more about your concerns
The Correct Answer is D
Rationale for Choice A:
A pelvic exam is required if you want birth control pills. This response is not therapeutic because it dismisses the client's feelings and does not address her concerns. It focuses on the policy or requirement rather than the client's emotional needs. It could make the client feel like her anxiety is not justified or that she has no choice in the matter.
Rationale for Choice B:
Don't worry, I will stay in there with you for the exam. While this response may be intended to provide reassurance, it does not fully address the client's underlying concerns. It offers a solution without first exploring the specific reasons for the client's anxiety. It could also make the client feel dependent on the nurse's presence for comfort, rather than empowering her to manage her own anxiety.
Rationale for Choice C:
All you need to do is relax during the exam. This response is not therapeutic because it minimizes the client's feelings and suggests that she can simply control her anxiety by relaxing. It does not acknowledge the validity of her concerns or provide any guidance on how to manage those concerns. It could make the client feel like her anxiety is her fault or that she is not coping well.
Rationale for Choice D:
Tell me more about your concerns. This is the most therapeutic response because it encourages the client to express her feelings and concerns openly. It validates the client's experience and demonstrates active listening and empathy. It provides an opportunity for the nurse to gather more information about the specific reasons for the client's anxiety and to tailor interventions accordingly. It also empowers the client by allowing her to share her thoughts and take control of the conversation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A:
While fetal maturity is a factor in the timing of amniocentesis, it's not the primary reason for waiting until 14 weeks.
Earlier in pregnancy, fetal cells are less abundant in the amniotic fluid, making it more challenging to obtain a sufficient sample for accurate testing.
Additionally, the procedure carries a slightly higher risk of miscarriage before 14 weeks.
Choice B:
The audibility of the fetal heartbeat is not directly related to the timing of amniocentesis.
It's typically possible to hear the heartbeat by Doppler ultrasound around 10-12 weeks, but this doesn't mean there's enough amniotic fluid for amniocentesis.
Choice D:
The accuracy of genetic results is not dependent on the timing of amniocentesis after 14 weeks.
As long as a sufficient sample of amniotic fluid is obtained, the accuracy of the results is not affected by gestational age.
Choice C:
The most accurate explanation for why amniocentesis is not performed before 14 weeks is the amount of amniotic fluid. Before 14 weeks, there's typically not enough amniotic fluid to safely extract a sample without potentially harming the fetus or the placenta.
By 14 weeks, there's usually enough fluid to adequately cushion the fetus and the needle during the procedure, reducing the risks involved.
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale: The recommended weight gain for a woman with a normal BMI (18.5-24.9) during pregnancy is 25-35 pounds. This range ensures adequate nutrition for both the mother and the developing baby, supporting optimal fetal growth and maternal health.
Choice B rationale: A weight gain of 11-20 pounds is recommended for women with a high BMI (≥30) during pregnancy. This range helps minimize the risk of complications such as gestational diabetes and hypertension, but it is not applicable for a woman with a normal BMI.
Choice C rationale: While a healthy diet is crucial, specific weight gain guidelines are essential to ensure the health of both mother and baby. Weight gain recommendations are based on evidence to support optimal outcomes, making it important to follow them.
Choice D rationale: A weight gain of 15-25 pounds is recommended for women with an overweight BMI (25-29.9) during pregnancy. This range helps support fetal growth while minimizing the risk of complications, but it is not applicable for a woman with a normal BMI.
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