A nurse is attending to a patient who is in preterm labor at 32 weeks of gestation. The patient asks the nurse, “Will my baby be okay?” What should the nurse respond?

“We have a neonatal unit here that’s equipped to handle emergencies.”.

“Everyone worries about their baby when they’re in labor.”.

“You must be feeling scared and powerless.”.

“Your pregnancy is advanced so your baby should be fine.”.

Answer and Explanation

The Correct Answer is A

Choice A rationale
The nurse should reassure the patient by informing her about the hospital’s capabilities to handle such situations. The neonatal unit in the hospital is equipped to handle emergencies and care for preterm babies. This response is factual and directly addresses the patient’s concern about the baby’s well-being.
Choice B rationale
While it’s true that everyone worries about their baby when they’re in labor, this response doesn’t directly address the patient’s concern about the baby’s health and well-being. It’s more of a general statement and doesn’t provide the reassurance the patient is seeking.
Choice C rationale
This response acknowledges the patient’s feelings, which is an important aspect of patient care. However, it doesn’t provide any information or reassurance about the baby’s health. The patient is specifically asking about the baby’s well-being, so the response should focus on that.
Choice D rationale
This response could be misleading. While it’s true that the chances of survival for preterm babies improve with each passing week, it’s not guaranteed that a baby born at 32 weeks will be fine. It’s important to provide accurate information and not give false reassurances.

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Correct Answer is A

Explanation

Choice A rationale
Monitoring vaginal bleeding is the priority nursing action for a client who is at 33 weeks of gestation and has a diagnosis of placenta previa. Placenta previa can cause painless, bright red vaginal bleeding during the third trimester. This bleeding can lead to serious complications for both the mother and the fetus, making it crucial to monitor for this symptom.
Choice B rationale
Administering glucocorticoids is not the priority nursing action in this situation. While glucocorticoids can be used to accelerate fetal lung maturity in cases of preterm labor, they are not the primary treatment for placenta previa.
Choice C rationale
Inserting an IV catheter may be necessary for administering medications or fluids, but it is not the priority action. The nurse’s primary concern should be monitoring for signs of bleeding.
Choice D rationale
Applying an external fetal monitor can help assess the well-being of the fetus, but it is not the priority action. The nurse’s main focus should be on monitoring for vaginal bleeding.

A. Insert an IV catheter. B. Assist the client into the left-lateral position. C. Apply a fetal scalp electrode. D. Perform a vaginal exam.

Correct Answer is B

Explanation

Choice A rationale
While inserting an IV catheter can be a part of the overall management plan for a client showing late decelerations on the electronic fetal monitor, it is not the initial course of action. The primary concern with late decelerations is that they may indicate fetal hypoxia, and the first response should be aimed at improving fetal oxygenation.
Choice B rationale
Assisting the client into the left-lateral position is the correct initial response when late decelerations are observed on the electronic fetal monitor. This position helps to maximize blood flow to the uterus and placenta, thereby improving oxygen delivery to the fetus.
Choice C rationale
Applying a fetal scalp electrode may be useful for obtaining a more accurate fetal heart rate tracing, but it is not the initial response to late decelerations. The priority is to address the potential fetal hypoxia that late decelerations may indicate.
Choice D rationale
Performing a vaginal exam would not be the initial response to late decelerations. While a vaginal exam can provide valuable information about the progress of labor, it does not address the issue of potential fetal hypoxia indicated by late decelerations.

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A nurse is attending to a patient who is in preterm labor at 32 weeks of gestation. The patient asks the nurse, “Will my baby be okay?” What should the nurse respond?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who is at 33 weeks of gestation and has a diagnosis of placenta previa. What is the priority nursing action?

Correct Answer is A

Explanation

A nurse is attending to a client in labor who is showing late decelerations on the electronic fetal monitor. What should be the nurse’s initial course of action?

Correct Answer is B

Explanation

A nurse is providing care for a client who is in preterm labor at 32 weeks of gestation. Which medication should the nurse expect the provider to prescribe to accelerate fetal lung maturity?

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