A nurse is caring for a female client who is scheduled to have a pelvic examination.
The client tells the nurse, "I'm really nervous because I've never had a pelvic exam before.”. Which of the following is an appropriate therapeutic response by the nurse?
"Tell me more about your concerns.”.
"All you need to do is relax during the exam.”.
"Don't worry.
"A pelvic exam is required if you want birth control pills.”.
will stay in there with you for the exam.”.
The Correct Answer is A
Choice A rationale:
"Tell me more about your concerns" is an appropriate therapeutic response by the nurse. It encourages the client to express her worries and fears about the pelvic examination. Open-ended questions like this one allow the nurse to better understand the client's specific concerns, which can help in addressing them effectively.
Choice B rationale:
"All you need to do is relax during the exam" may come across as dismissive and may not address the client's anxiety effectively. It's important to acknowledge the client's feelings and offer support rather than making the situation seem overly simplistic.
Choice C rationale:
"Don't worry. I will stay in there with you for the exam" might make the client feel like she has no control over the situation and can be invasive. While offering support is important, it's essential to respect the client's autonomy and provide emotional support through active listening and communication.
Choice D rationale:
"A pelvic exam is required if you want birth control pills" is not an appropriate response to the client's anxiety about the pelvic exam. This response does not address the client's concerns and may not provide the necessary emotional support or information she needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Has mitral valve insufficiency. This client's medical condition is not an indication for an amniotic fluid alpha-fetoprotein screening. Alpha-fetoprotein screening is typically used to assess the risk of neural tube defects and chromosomal abnormalities in the fetus. Mitral valve insufficiency is unrelated to this screening.
Choice B rationale:
History of preterm labor. A history of preterm labor is not a direct indication for amniotic fluid alpha-fetoprotein screening. This screening is primarily used to detect neural tube defects and chromosomal abnormalities in the fetus. Preterm labor history is not related to these conditions.
Choice C rationale:
History of delivering a child with a neural tube defect. This is the correct choice. A history of delivering a child with a neural tube defect is a strong indication for amniotic fluid alpha-fetoprotein screening. The screening is used to assess the risk of neural tube defects in subsequent pregnancies. It is crucial for early detection and management if the risk is high.
Choice D rationale:
Has been exposed to AIDS. Exposure to AIDS (HIV) is not a direct indication for amniotic fluid alpha-fetoprotein screening. This screening is primarily focused on assessing fetal health and the risk of specific congenital abnormalities. HIV exposure is unrelated to the purpose of this screening.
Correct Answer is A
Explanation
Choice A rationale:
Checking the fetal heart rate pattern is the priority nursing action following an amniotomy. This procedure involves rupturing the amniotic membranes, which can result in changes to the baby's heart rate. It's essential to assess the fetal heart rate to ensure the baby is tolerating the procedure well and to identify any signs of fetal distress promptly.
Choice B rationale:
Evaluating the client for signs of infection is an important step after an amniotomy, but it is not the top priority. The immediate concern is the well-being of the fetus, and assessing the fetal heart rate takes precedence.
Choice C rationale:
Taking the client's temperature is relevant to monitor for infection, but it should not be the first action. Monitoring the fetus's status with a fetal heart rate assessment is more critical in this situation.
Choice D rationale:
Observing the color and consistency of amniotic fluid is a valuable assessment but not the top priority. It can provide information about meconium staining or other issues, but assessing the fetal heart rate is more crucial immediately after the procedure.
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