A nurse is caring for a client who is at 14 weeks of gestation. Which of the following statements should the nurse identify as the client being emotionally prepared for pregnancy?
"If I keep gaining weight, I will be miserable."
"I cannot believe I got pregnant. We really weren't even trying to have a baby."
"I understand that hormonal changes can cause me to be happy one minute and sad the next."
"This baby will totally change my lifestyle, and I am not sure I am ready for all of this."
The Correct Answer is C
A. "If I keep gaining weight, I will be miserable." Expressing anxiety about weight gain reflects a lack of emotional readiness and acceptance regarding the physical changes that accompany pregnancy.
B. "I cannot believe I got pregnant. We really weren't even trying to have a baby." Indicating surprise suggests a lack of preparation for the emotional and practical aspects of pregnancy. This reflects that the client may not have fully accepted the reality of the situation.
C. "I understand that hormonal changes can cause me to be happy one minute and sad the next." Recognizing and accepting the emotional fluctuations that can occur during pregnancy due to hormonal changes indicates a level of emotional preparation for the journey ahead.
D. "This baby will totally change my lifestyle, and I am not sure I am ready for all of this." Acknowledging the impact of having a baby on lifestyle is important, but expressing uncertainty suggests that the client may still be struggling with the implications of becoming a parent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "I will wipe away yellow crusts that form around the incision." Yellow crusting at the incision site is a normal part of the healing process. It should not be wiped away, as doing so could disrupt healing and cause irritation or bleeding. Instead, the area should be kept clean and allowed to heal naturally.
B. "I will apply antibiotic ointment to my baby's penis." The Plastibell technique does not require the application of antibiotic ointment. Unlike other circumcision methods, the Plastibell ring remains in place and falls off on its own within 5 to 8 days, reducing the need for additional topical treatments.
C. "I will make sure that my baby's diaper is applied snugly." The diaper should be applied loosely to prevent excessive pressure or friction on the healing area. A snug diaper can cause discomfort and increase irritation, potentially delaying healing.
D. "I will apply pressure with gauze if I see bleeding." Minor bleeding may occur after circumcision, and applying gentle pressure with sterile gauze is the appropriate action to control it. If bleeding persists beyond a few minutes or is excessive, medical attention should be sought immediately.
Correct Answer is B
Explanation
A. New onset of hearing loss. Gentamicin is an aminoglycoside antibiotic known for its ototoxic effects, which can lead to irreversible hearing loss or vestibular dysfunction. The drug damages the hair cells in the inner ear, resulting in symptoms like tinnitus, dizziness, or difficulty hearing. Clients receiving gentamicin should be closely monitored for auditory changes, as early detection can help prevent worsening damage.
B. Constipation. Gentamicin does not typically affect gastrointestinal motility, making constipation an unlikely adverse effect. It primarily causes nephrotoxicity and ototoxicity, with its main targets being the kidneys and inner ear. Gastrointestinal side effects are rare and usually limited to nausea or mild discomfort rather than significant bowel irregularities.
C. Slurred speech. While aminoglycosides can cause neuromuscular blockade in rare cases, slurred speech is not a common adverse effect. More frequently, gentamicin affects the vestibular system, leading to balance disturbances or dizziness rather than impairing speech function. If neuromuscular symptoms develop, the medication should be reassessed to prevent severe complications.
D. Hypotension. Gentamicin does not directly cause hypotension as a primary side effect. Its adverse effects are more commonly associated with kidney damage, ototoxicity, and, in rare cases, neuromuscular paralysis. If a client on gentamicin experiences hypotension, other underlying causes such as sepsis or volume depletion should be considered.
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