A nurse is caring for a client at a 10-week prenatal visit. The provider diagnoses the client with a missed spontaneous abortion confirmed by ultrasound and the nurse is discussing the plan of care with the client.
Which of the following statements should the nurse make?
"It can be helpful to talk about your loss with others who have experienced a pregnancy loss.”.
"Once the fetus is passed, the provider will likely be able to determine what caused the pregnancy loss.”.
"I have found that it is best to avoid seeing the fetal remains after the procedure.”.
"It is okay to feel some grief now, even though it is so early in the pregnancy for a loss.”.
Correct Answer : A
Choice A rationale
Providing an opportunity to connect with others who have experienced similar losses offers significant psychosocial support. Sharing experiences can normalize grief, reduce feelings of isolation, and validate emotions. This peer support can facilitate the grieving process by fostering a sense of community and understanding during a challenging time.
Choice B rationale
While some causes of spontaneous abortion can be identified, many remain unknown even after the expulsion of fetal tissue. Genetic anomalies, chromosomal abnormalities, or uterine factors are often implicated, but a definitive cause is not always determined. Providing this information can create unrealistic expectations and potential disappointment for the client.
Choice C rationale
The decision to view fetal remains is highly personal and depends on individual coping mechanisms and cultural beliefs. For some, it can be a crucial part of acknowledging the loss and beginning the grieving process. Advising against it prematurely removes a potential avenue for closure and validation for the client.
Choice D rationale
Telling the client it is okay to feel grief “even though it is early in the pregnancy” can unintentionally minimize their feelings; grief is valid at any gestational age, and phrasing should normalize the loss without implying it is less significant.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
A client at 12 weeks of gestation not feeling fetal movement is expected. Fetal movement, or quickening, typically begins between 16 and 20 weeks of gestation for primigravidas and earlier for multigravidas. At 12 weeks, the fetus is still small and movements are not usually strong enough to be consistently perceived by the mother, thus this finding is not immediately concerning.
Choice B rationale
A fetal heart rate (FHR) of 160/min at 28 weeks of gestation is within the normal range, which is typically 110-160 beats/min. A normal FHR indicates adequate fetal oxygenation and well-being. Therefore, this finding does not suggest an emergent situation requiring immediate provider assessment.
Choice C rationale
Deep tendon reflexes (DTRs) graded as 2+ are considered normal. This grading indicates an average, brisk reflex response. Abnormal DTRs, such as hyperreflexia (3+ or 4+), can be indicative of preeclampsia, but a 2+ finding is physiological and does not warrant immediate concern.
Choice D rationale
Blurred vision in a client at 36 weeks of gestation can be a symptom of preeclampsia, a serious hypertensive disorder of pregnancy. This condition can lead to severe complications such as eclampsia, placental abruption, or HELLP syndrome, requiring immediate medical evaluation and intervention to prevent adverse maternal and fetal outcomes.
Correct Answer is C
Explanation
Choice A rationale
The critical congenital heart disease (CCHD) screening is typically performed when the newborn is between 24 and 48 hours of age, or just prior to discharge if that occurs earlier. Performing the test too early, such as between 6 and 12 hours, might yield false negative results due to the persistence of transitional circulation.
Choice B rationale
The results of the CCHD screening are typically available immediately, or within a few minutes, as it involves pulse oximetry readings. There is no waiting period of 1 to 2 weeks for the results, allowing for prompt identification and management of potential cardiac defects, preventing delays in care.
Choice C rationale
The CCHD screening specifically compares the oxygen saturation in the newborn's right hand (pre-ductal) and either foot (post-ductal). A significant difference between these two readings can indicate a shunt or obstruction within the heart or great vessels, suggesting a potential critical congenital heart defect.
Choice D rationale
Collecting a blood sample from the newborn's heel is the procedure for the newborn metabolic screening, which screens for various genetic and metabolic disorders, not the critical congenital heart disease screening. The CCHD screening is a non-invasive test performed using pulse oximetry.
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