A client at 9 weeks gestation tells the nurse that while she has cut down, she still has at least one alcoholic drink every evening before bedtime. Which intervention should the nurse implement?

Notify child protective services of the client’s illicit drug use and probable child endangerment.

Praise the client for her actions and offer to discuss ways to decrease consumption even more.

Refer the client to an outpatient alcohol abuse program for disulfiram therapy.

Insist that the client stop all alcohol use and draw a blood alcohol level at each prenatal visit.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Notifying child protective services without further assessment may cause unnecessary distress and legal complications. The client's current alcohol use reduction efforts should be considered, and other interventions can be explored first.

Choice B rationale

Praising the client for reducing alcohol intake encourages positive behavior. Providing support and discussing ways to further decrease consumption promotes a collaborative approach to reducing alcohol exposure during pregnancy.

Choice C rationale

Disulfiram therapy is not suitable for pregnant clients due to potential risks. Instead, referral to an outpatient alcohol abuse program for counseling and support is more appropriate and safer for both mother and fetus.

Choice D rationale

Insisting on complete alcohol cessation without providing support may result in non-compliance. Drawing blood alcohol levels at each visit may cause anxiety and is not a practical approach for monitoring alcohol use in pregnancy.

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Correct Answer is A

Explanation

Choice A rationale

SROM for 36 hours before delivery significantly increases the risk of postpartum endometritis due to prolonged exposure of the uterine cavity to potential pathogens. Prompt antibiotic therapy may be required to prevent infection.

Choice B rationale

Labor lasting for 24 hours can contribute to maternal fatigue and increased risk of complications, but it is not the primary factor for postpartum endometritis. The duration of rupture of membranes is more critical in this context.

Choice C rationale

A third-degree perineal laceration poses a risk for infection at the wound site but is not the leading cause of postpartum endometritis. The primary concern remains the extended duration of ruptured membranes.

Choice D rationale

Epidural anesthesia is not directly associated with an increased risk of postpartum endometritis. Its primary effects are related to pain management and potential impacts on labor progression, not infection risk.

A. Ask a nurse with more experience to validate the costal angle finding. B. Examine the client for signs of tissue anoxia, such as pallor. C. Ask the healthcare provider to evaluate the client’s respiratory status. D. Record the respiratory finding in the client’s record as normal.

Correct Answer is D

Explanation

Choice A rationale

Asking another nurse to validate the costal angle finding is unnecessary, as the increased costal angle is a common physiological change during pregnancy due to the expanding uterus.

Choice B rationale

Examining for tissue anoxia, such as pallor, is not relevant in this scenario, as the nasal stuffiness and nosebleeds are likely due to increased blood volume and hormonal changes in pregnancy.

Choice C rationale

Requesting the healthcare provider to evaluate the client's respiratory status is unwarranted, as the described symptoms are typical physiological adaptations during pregnancy and not indicative of respiratory pathology.

Choice D rationale

Documenting the respiratory finding as normal is appropriate, as the increased chest circumference, thoracic breathing, elevated diaphragm, and increased costal angle are expected physiological changes during pregnancy.

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A client at 9 weeks gestation tells the nurse that while she has cut down, she still has at least one alcoholic drink every evening before bedtime. Which intervention should the nurse implement?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Correct Answer is D

Explanation

A primigravida client with gestational hypertension and a Bishop score of 3 is scheduled for induction of labor. The nurse administers misoprostol at 0700, then observes regular contractions with cervical changes at 0900. Which action should the nurse take?

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