A nurse is caring for an adolescent client who is pregnant with their second child and is experiencing anxiety. Which of the following statements should the nurse make?
"Tell me more about how you are feeling about this pregnancy."
"Clients are usually happy about a second pregnancy."
“You will feel better when you have your first ultrasound."
"Let's focus on how you are feeling physically."
The Correct Answer is A
Rationale:
A. "Tell me more about how you are feeling about this pregnancy.": This open-ended, therapeutic statement encourages the adolescent to express her thoughts and emotions. It shows empathy and supports trust-building, which is essential in managing anxiety and promoting emotional well-being.
B. "Clients are usually happy about a second pregnancy.": This response generalizes experiences and dismisses the client’s individual feelings. It may cause the client to feel misunderstood or pressured to conform to others' expectations.
C. "You will feel better when you have your first ultrasound.": This statement minimizes the client’s current emotional state and assumes that reassurance will come from a future event, which may not address the underlying anxiety.
D. "Let's focus on how you are feeling physically.": While physical symptoms are important, this response deflects from the client's expressed emotional concern. It can shut down conversation about her psychological well-being, which is the main issue presented.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"}}
Explanation
Rationale:
- Prolonged rupture of membranes: Membranes ruptured for over 24 hours (28 hr), increasing the risk for ascending bacterial infections such as endometritis or chorioamnionitis.
- Prenatal anemia: Anemia reduces immune function and tissue oxygenation, making the client more susceptible to postpartum infections, including uterine and systemic infections.
- Polyhydramnios: Excessive amniotic fluid causes uterine overdistension, which weakens uterine contractility and increases the risk of atony and postpartum hemorrhage.
- High parity: Repeated stretching of the uterus in grand multiparity reduces muscle tone, making the uterus less responsive to postpartum contraction and more prone to atony.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D"}
Explanation
Rationale for Correct Choices:
- Seizures: The client presents with severe preeclampsia, indicated by BP >160/110 mm Hg, 3+ proteinuria, hyperreflexia (patellar reflex 4+), and persistent headache. These are strong predictors of progression to eclampsia, which is marked by seizures.
- Placental Abruption: Severe hypertension increases the risk of placental abruption due to vascular compromise in the uteroplacental circulation. Decreased fetal movement may be an early warning sign of impaired placental perfusion or separation.
Rationale for Incorrect Choices:
- Cervical Insufficiency: This is a painless cervical dilation often leading to second-trimester loss, unrelated to hypertension or proteinuria. The client is in the third trimester with no signs of cervical changes.
- Hypoglycemia: The client has no history of diabetes, glucose intolerance, or related symptoms. Her urine glucose was only trace, and no medications suggest insulin use.
- Heart Failure: No signs of pulmonary congestion, dyspnea, or elevated heart rate are present. Oxygen saturation is normal, and breath sounds are not mentioned as abnormal, making CHF unlikely at this stage.
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