A nurse in a prenatal clinic is caring for a client who reports that her menstrual period is 2 weeks late. The client appears anxious and asks the nurse if she is pregnant. Which of the following responses should the nurse make?
"You can miss your period for several other reasons. Describe your typical menstrual cycle
"If you have been sexually active and haven't used protection it is likely that you are pregnant
"Let's check to see if you have any other signs of pregnancy. Have you noticed any abdominal enlargement yet?
"Because you have missed your period, you should try taking a home pregnancy test before you start worrying
The Correct Answer is A
Choice A Reason:
"You can miss your period for several other reasons. Describe your typical menstrual cycle." This response acknowledges that a missed period can result from various factors other than pregnancy, such as stress, changes in weight, hormonal fluctuations, or certain medical conditions. Understanding the client's typical menstrual cycle can help the nurse gather more information about potential reasons for the late period.
Choice B Reason:
"If you have been sexually active and haven't used protection, it is likely that you are pregnant. “This response assumes pregnancy without exploring other possibilities or the client's individual situation.
Choice C Reason:
"Let's check to see if you have any other signs of pregnancy. Have you noticed any abdominal enlargement yet?" While considering other signs of pregnancy is reasonable, focusing on abdominal enlargement may not be the most accurate early indicator, and it's essential to explore a broader range of symptoms.
Choice D Reason:
"Because you have missed your period, you should try taking a home pregnancy test before you start worrying. "While suggesting a home pregnancy test is reasonable, it may be more beneficial to gather additional information about the client's menstrual cycle and potential symptoms before jumping directly to a test.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is B.
A. Increased fetal movement: Increased fetal movement is generally not considered a complication after an amniocentesis. Fetal movement is a positive sign, indicating fetal well-being. However, it's important to monitor for any changes in movement patterns.
B. Leakage of fluid from the vagina: Leakage of amniotic fluid from the vagina is a potential complication after amniocentesis. It may indicate rupture of the amniotic sac, which can lead to preterm labor and other complications. This finding should be reported promptly to the healthcare provider.
C. Upper abdominal discomfort: Mild upper abdominal discomfort can occur after an amniocentesis, but it is not typically a severe complication. It may be related to the procedure itself and often resolves with rest. However, persistent or severe discomfort should be reported.
D. Urinary frequency: Urinary frequency is not typically associated with complications after an amniocentesis. It may be a normal symptom related to the position of the uterus or other factors, but it does not generally warrant immediate reporting as a complication.
Correct Answer is D
Explanation
The correct answer is D.
A. Insert the syringe tip before compressing the bulb: This is incorrect. The nurse should compress the bulb syringe first, then gently insert the tip into the newborn's nose, and then release the bulb to create suction for removing the mucus.
B.The client should suction the mouth first then the nares.
C. Insert the tip of the syringe into the center of the newborn's mouth: This is incorrect. The tip of the bulb syringe should be inserted into the side of the baby's mouth to avoid causing discomfort or stimulating the gag reflex.
D. When the newborn's cry may sound clear due to vocalization, but this may indicate that the airways are clear of secretions.
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