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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.

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Correct Answer is A

Explanation

A) Urinary output 40 mL in 2 hr:
A urinary output of 40 mL in 2 hours is significantly low and could indicate decreased renal perfusion, which may be a sign of magnesium sulfate toxicity. Therefore, the nurse should report this finding to the provider promptly.

B) Fetal heart rate 158/min:
A fetal heart rate of 158/min is within the normal range for a fetus and is not directly related to the client's magnesium sulfate therapy. This finding does not require immediate reporting.

C) Headache for 30 min:
While headaches can be a symptom of preeclampsia, in this case, the headache is mild and of short duration. It may not necessarily indicate a complication related to magnesium sulfate therapy. However, it should be monitored, but it does not require immediate reporting.

D) Respirations 16/min:
A respiratory rate of 16/min is within the normal range for an adult and is not indicative of magnesium sulfate toxicity. This finding does not require immediate reporting.

A. "There is an increased risk of rupture of the membranes. B. "There is an increased risk of introducing infection." C. "This could initiate preterm labor." D. "This could result in profound bleeding."

Correct Answer is D

Explanation

A) "There is an increased risk of rupture of the membranes": While there is a risk of premature rupture of membranes with placenta previa, the primary reason for avoiding internal examinations is the potential for profound bleeding. Internal examinations can dislodge the placenta, leading to significant hemorrhage, rather than directly causing rupture of the membranes.

B) "There is an increased risk of introducing infection": While infection is a concern with any internal procedure, the primary reason for avoiding internal examinations in placenta previa is the risk of provoking bleeding.

C) "This could initiate preterm labor": Internal examinations in placenta previa are not typically associated with initiating preterm labor. The primary concern is the risk of significant bleeding due to disruption of the placenta.

D) "This could result in profound bleeding": This is the correct explanation. Performing internal examinations in placenta previa increases the risk of dislodging the placenta, leading to severe bleeding. Avoiding unnecessary internal examinations helps minimize this risk and promotes the safety of both the mother and the baby.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is receiving magnesium sulfate to treat pre-eclampsia. Which of the following findings should the nurse report to the provider?

Correct Answer is A

Explanation

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?

Correct Answer is D

Explanation

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A nurse is assessing a client who received magnesium sulfate to treat preterm labor. Which of the following clinical findings should the nurse identify as an indication of toxicity of magnesium sulfate therapy and report to the provider?

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