Given the medical history and nurses’ notes of an infant diagnosed with Tetralogy of Fallot, which of the following actions should the nurse take?

Choice A rationale
The nurse should reassure the patient by informing her about the hospital’s capabilities to handle such situations. The neonatal unit in the hospital is equipped to handle emergencies and care for preterm babies. This response is factual and directly addresses the patient’s concern about the baby’s well-being.
Choice B rationale
While it’s true that everyone worries about their baby when they’re in labor, this response doesn’t directly address the patient’s concern about the baby’s health and well-being. It’s more of a general statement and doesn’t provide the reassurance the patient is seeking.
Choice C rationale
This response acknowledges the patient’s feelings, which is an important aspect of patient care. However, it doesn’t provide any information or reassurance about the baby’s health. The patient is specifically asking about the baby’s well-being, so the response should focus on that.
Choice D rationale
This response could be misleading. While it’s true that the chances of survival for preterm babies improve with each passing week, it’s not guaranteed that a baby born at 32 weeks will be fine. It’s important to provide accurate information and not give false reassurances.

Choice A rationale
The nurse should be concerned about a client with an 18kg (4 lb) weight gain in her first trimester. This is because the expected weight gain for a client in the first trimester is usually around 1.8 kg (4 lb)1. A weight gain of 18 kg in the first trimester significantly exceeds this expectation, which could indicate a potential health issue such as gestational diabetes or multiple pregnancies. It’s important for the nurse to report this finding to the healthcare provider for further evaluation and management.
Choice B rationale
A client with a 68 kg (15 lb) weight gain in her second trimester does not necessarily pose a concern. Weight gain during pregnancy varies among individuals and can be influenced by factors such as the mother’s body mass index (BMI) before pregnancy, the baby’s growth rate, and the mother’s diet and lifestyle. However, it’s always important to monitor weight gain throughout pregnancy to ensure it’s within a healthy range.
Choice C rationale
A client with a 13 kg (25 lb) weight gain in her third trimester does not necessarily pose a concern. Weight gain during the third trimester can be influenced by factors such as the baby’s growth rate, amniotic fluid volume, and the mother’s increased blood volume. However, it’s always important to monitor weight gain throughout pregnancy to ensure it’s within a healthy range.
Choice D rationale
A client with a 3.6 kg (8 lb) weight gain in her first trimester does not necessarily pose a concern. This is within the expected weight gain range for the first trimester. However, it’s always important to monitor weight gain throughout pregnancy to ensure it’s within a healthy range.