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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Documenting the finding in the medical record is routine, but it does not address the potential concern of the fundal height discrepancy, which may indicate a need for further evaluation.
Choice B rationale
Scheduling a biophysical profile is crucial to assess the well-being of the fetuses, especially given the discrepancy in fundal height, which could indicate issues such as growth restriction or polyhydramnios.
Choice C rationale
Requesting another nurse to measure the fundus might help verify the measurement but does not address the potential underlying issue, which requires further assessment like a biophysical profile.
Choice D rationale
Notifying the healthcare provider is necessary, but it is more appropriate to first schedule a biophysical profile to gather comprehensive information on the fetal well-being before consulting the provider.
Correct Answer is A
Explanation
Choice A rationale
The postpartum period is characterized by leukocytosis, where WBC counts can rise to 30,000/mm³ due to physiological stress. A WBC count of 15,000/mm³ is within the expected range for this client.
Choice B rationale
Perineal hematomas are more likely to cause localized pain and swelling than systemic symptoms. The assessment of perineal area is important but not the first priority in this context.
Choice C rationale
Monitoring temperature, heart rate, and respirations is crucial to identify infection but checking the differential to confirm normal physiological response to postpartum is prioritized first.
Choice D rationale
Notifying the HCP for an elevated WBC count without additional signs of infection is premature. A WBC count of 15,000/mm³ alone is not indicative of an infection in postpartum clients.
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