Try Naxlex NCLEX-RN (Free-Trial)

A nurse is caring for a client who is in preterm labor at 32 weeks of gestation. The client asks the nurse. "Will my baby be okay?" Which of the following responses should the nurse offer?

"We have a neonatal unit here that's equipped to handle emergencies."

"Your pregnancy is advanced so your baby should be fine.

"You must be feeling scared and powerless.

"Everyone worries about her baby when she's in labor."

None

Answer and Explanation

The Correct Answer is C

Answer: C. "You must be feeling scared and powerless."

Rationale:

A. "We have a neonatal unit here that's equipped to handle emergencies.
This response provides factual information but fails to acknowledge the client's emotional distress. While it may offer some reassurance, it does not directly validate the client's fears or foster therapeutic communication.

B. "Your pregnancy is advanced so your baby should be fine."
This statement offers premature reassurance without addressing the client’s emotional needs. It overlooks the potential risks of preterm birth at 32 weeks and may give a false sense of security, which could undermine trust if complications arise.

C. "You must be feeling scared and powerless."
This response reflects therapeutic communication by acknowledging the client’s emotional experience. It invites further discussion, demonstrates empathy, and builds a trusting relationship, which is essential during high-stress situations like preterm labor.

D. "Everyone worries about her baby when she's in labor."
This generalization minimizes the client’s individual feelings. It may make the client feel dismissed or that her concerns are not unique or important, which can hinder open, supportive communication.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A) Keep four side rails up while the client is in bed:
This action is not directly related to the care of a client in active labor. Side rails should be used based on the client's mobility status and fall risk, not specifically because the client is in labor.

B) Monitor the fetal heart rate (FHR) every hour:
Fetal heart rate monitoring is essential during labor, but hourly monitoring may not be frequent enough to detect changes in fetal status. Continuous or more frequent monitoring is typically indicated during active labor.

C) Check the cervix prior to analgesic administration:
This is an essential action as it ensures that analgesic administration is appropriate based on the client's cervical dilation. Administering analgesics when the cervix is fully dilated can increase the risk of neonatal depression. Therefore, assessing the cervix before administering analgesia is crucial.

D) Insert an indwelling urinary catheter:
Routine urinary catheterization during labor is not recommended unless medically necessary. There is no indication in the scenario that suggests the need for catheterization.

A. Fundus palpable at the umbilicus B. Heart rate 110/min C. Urine output of 3,000 mL in 12 hr D. Orthostatic hypotension

Correct Answer is B

Explanation

A) Fundus palpable at the umbilicus:
At 12 hours postpartum, it is normal for the fundus to be at the level of the umbilicus. This finding is expected as the uterus begins its process of involution.

B) Heart rate 110/min:
A heart rate of 110/min is indicative of tachycardia, which can be a sign of postpartum complications such as hemorrhage, infection, or dehydration. Tachycardia is concerning because it may indicate that the body is compensating for a significant loss of blood or other underlying issues.

C) Urine output of 3,000 mL in 12 hr:
Increased urine output is common in the immediate postpartum period as the body eliminates excess fluid retained during pregnancy. This is not indicative of a complication and is generally considered a normal finding.

D) Orthostatic hypotension:
Orthostatic hypotension can occur postpartum due to the body's adjustments after delivery and fluid shifts. While it needs to be monitored, it is not as immediate a concern as tachycardia, which could indicate more serious complications.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client who is in preterm labor at 32 weeks of gestation. The client asks the nurse. "Will my baby be okay?" Which of the following responses should the nurse offer?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is creating the plan of care for a client who is at 39 weeks of gestation and in active labor. Which of the following actions should the nurse include in the plan of care?

Correct Answer is C

Explanation

A nurse is caring for a client who is 12 hr postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication?

Correct Answer is B

Explanation

A nurse is caring for a client 2 hr after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-min period. Which of the following is the priority nursing intervention at this time?

A nurse is preparing to administer lithium 300 mg PO every 8 hr. Available is lithium carbonate 150 mg capsules. How many capsules should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is performing Leopold maneuvers on a client who is in labor and determines the fetus is in an RSA position. Which of the following fetal presentations should the nurse document in the client's medical record?

A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct Interpretation of this clinical finding?

A nurse is preparing a client who is in active labor for epidural analgesia. Which of the following actions should the nurse take?

A nurse is caring for a client who is at 37 weeks of gestation and has placenta previa. The client asks the nurse why the provider does not do an internal examination. Which of the following explanations of the primary reason should the nurse provide?

A nurse in is caring for a client who is to undergo an amniotomy. Which of the following is the priority nursing action following this procedure?

A nurse is preparing to administer amoxicillin 250 mg PO every 8 hr. The amount available is amoxicillin 125 mg tablets. How many tablets should the nurse administer with each dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)