A client with a history of three spontaneous abortions is now at 16 weeks' gestation and expresses a concern about remaining at home during pregnancy.
Which query will elicit a response most helpful to the nurse developing the client's plan of care?
Are you aware of how a healthy lifestyle affects a pregnancy?
Do you know the causes related to the spontaneous abortions?
What are the characteristics of an impending spontaneous abortion?
What have you been told about the status of your pregnancy?
The Correct Answer is D
Choice A rationale
This question focuses on general health knowledge, which, while important, doesn't directly address the client's current psychological distress and anxiety related to her history of recurrent pregnancy loss and current concern about being at home. The plan of care needs to first establish the client's understanding and perception of her current pregnancy status.
Choice B rationale
Understanding the etiology of previous spontaneous abortions, such as chromosomal abnormalities or uterine anomalies, is valuable for medical management but may not be known and doesn't immediately address the client's current, expressed anxiety about remaining at home. The most helpful response first assesses the client's current belief system regarding this specific pregnancy.
Choice C rationale
Asking about signs of an impending spontaneous abortion focuses on potential complications, which could increase the client's anxiety. While patient education is crucial, the initial priority is to understand the client's current knowledge and perception of her present pregnancy status, which is key to tailoring support.
Choice D rationale
This question is most helpful because it assesses the client's current understanding of her pregnancy's stability, which directly relates to her expressed concern about staying home. A clear understanding of the fetal and maternal status provides the necessary foundation for the nurse to plan appropriate supportive care and education.
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Correct Answer is C
Explanation
Choice A rationale
This is an unscientific and dismissive response. There is a clear physiological reason for increased neonatal mucus following a cesarean birth. During a normal vaginal delivery, the thoracic squeeze exerted by the birth canal helps physically expel lung fluid and mucus, aiding the transition to extrauterine respiration.
Choice B rationale
While individual differences exist, this response fails to address the specific pathophysiology associated with the increased mucus observed in cesarean-born neonates. The lack of vaginal compression is a known factor that significantly impacts the clearance of fetal lung fluid and mucus, leading to transient tachypnea.
Choice C rationale
The lack of the "thoracic squeeze" during a cesarean birth means less fetal lung fluid and mucus are mechanically cleared compared to a vaginal birth. This remaining fluid can manifest as increased mucus-like secretions and often leads to conditions like Transient Tachypnea of the Newborn (TTN) as the lungs absorb the remaining fluid.
Choice D rationale
Pain medications like opioids, which may cross the placenta, primarily cause neonatal respiratory depression by acting on the central nervous system's respiratory centers, not by directly causing a physical build-up or inadequate clearance of mucus in the respiratory tract. Mucus clearance is a mechanical process.
Correct Answer is C
Explanation
Choice A rationale
Administering oxygen is an appropriate intervention for fetal distress (normal FHR is 110-160 beats/min), but the immediate, precipitating cause of this sudden, profound bradycardia after amniotomy must first be determined. Oxygen is secondary to resolving the likely mechanical issue of a prolapsed cord.
Choice B rationale
Increasing intravenous fluids (IVFs) may improve maternal hydration and thus placental perfusion, which can sometimes help with mild FHR decelerations. However, it is not the immediate priority for a severe, acute drop to 80 beats/min after membrane rupture, which strongly suggests umbilical cord prolapse.
Choice C rationale
A sudden, severe FHR drop after amniotomy is highly indicative of umbilical cord prolapse, where the cord drops below the presenting part and is compressed. Inspecting the vagina (or performing a sterile vaginal examination) is the priority to visually or digitally confirm the presence of a prolapsed cord so immediate action can be taken to relieve compression.
Choice D rationale
Placing the client in the knee-chest position (or Trendelenburg) is done after confirming cord prolapse to use gravity to move the fetus off the compressed cord. The most immediate action is to diagnose the cause of the distress, as time is critical to prevent severe fetal hypoxia and injury.
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