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 A
Explanation
The correct answer is A.
A. Oligohydramnios: Oligohydramnios is a condition characterized by a lower-than-normal level of amniotic fluid in the uterus. Fetal assessment using electronic fetal monitoring may be indicated to monitor the well-being of the fetus, as oligohydramnios can be associated with fetal growth restriction and other complications.
B. Hyperemesis gravidarum: Hyperemesis gravidarum refers to severe nausea and vomiting during pregnancy. While it can be a challenging condition, it is not typically an indication for electronic fetal monitoring. Fetal monitoring is generally performed for conditions that directly impact the well-being of the fetus.
C. Leukorrhea: Leukorrhea refers to an increase in vaginal discharge, which is a common and normal occurrence during pregnancy. It is not an indication for electronic fetal monitoring, as it does not directly impact fetal well-being.
D. Periodic tingling of the fingers: Periodic tingling of the fingers is not typically an indication for fetal assessment using electronic fetal monitoring. It may be related to factors such as nerve compression or changes in circulation but is not a direct indication for monitoring the fetus.
Correct Answer is A
Explanation
A. After notifying the provider, the nurse should massage the client’s fundus. This action helps to contract the uterus and reduce bleeding, which is crucial in managing hypovolemic shock due to postpartum hemorrhage.
B. Insert an indwelling urinary catheter: This action is important for monitoring urine output, which is a key indicator of renal perfusion and overall fluid status. However, it is not the immediate priority when managing hypovolemic shock due to postpartum hemorrhage.
C. Administer oxygen at 10 L/min: Providing oxygen is crucial to ensure adequate tissue oxygenation, especially in a shock state. While important, it comes after addressing the source of bleeding, which is the primary cause of the hypovolemic shock.
D. Elevate the client’s right hip: This action helps to prevent uterine displacement and improve venous return, which can be beneficial. However, it is not the first step in managing hypovolemic shock due to postpartum hemorrhage.
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