At a fertility clinic, a nurse is being asked by a client taking clomiphene citrate regarding the risk of multiple births.
The nurse's best response to this client would be:
Would you like to discuss this further before your treatment begins.
No one has ever had more than triplets.
Ovulation will be monitored with ultrasound so this will not happen.
Ten percent is a very low risk, so you don't need to worry.
The Correct Answer is D
Choice A rationale
While this response is empathetic and open-ended, it does not directly answer the client's specific question regarding the risk of multiple births. In a clinical setting, clients require factual information to make informed decisions about their care. Asking if they want to discuss it further without providing the necessary statistics or scientific context fails to address the immediate knowledge deficit. Effective nursing communication should combine supportive inquiry with accurate, evidence-based data.
Choice B rationale
This statement is factually incorrect and provides false reassurance. Clomiphene citrate stimulates the release of follicle-stimulating hormone and luteinizing hormone, which can lead to the maturation and ovulation of multiple follicles. While twins are the most common multiple birth associated with this medication, higher-order multiples like quadruplets or quintuplets have been documented. Telling a client that more than triplets is impossible is a violation of the duty to provide truthful medical information.
Choice C rationale
Ultrasound monitoring is indeed used to track the number and size of developing follicles during a medicated cycle. However, monitoring alone does not prevent the physiological occurrence of multiple ovulation. Even if multiple follicles are seen, the medication has already been administered, and the risk remains if the couple engages in intercourse. The nurse cannot guarantee that multiple births will not happen simply because the client is being monitored by the healthcare team.
Choice D rationale
Clomiphene citrate is associated with a multiple pregnancy rate of approximately 5 percent to 10 percent, with the vast majority being twins. Providing this specific percentage gives the client a clear, evidence-based understanding of the risk. Stating that 10 percent is relatively low helps put the risk in perspective while acknowledging that the possibility exists. This response is the most scientifically accurate and helpful for a client weighing the pros and cons of treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Postpartum blues represent a transient period of emotional lability occurring in approximately 80.
Choice B rationale
The taking-in phase is a behavioral stage identified by Reva Rubin where the mother is focused on her own needs for food, fluid, and sleep. While she may be talkative about her birth experience, this phase does not specifically explain the spontaneous crying and emotional fragility described by the patient at four days postpartum. Attachment difficulties usually involve a lack of interest in the newborn rather than the emotional overflow associated with the baby blues.
Choice C rationale
Postpartum depression is a more intense and persistent clinical condition that typically develops after the first few weeks following childbirth. It involves deeper feelings of hopelessness, severe anxiety, and potential suicidal ideation that interfere with daily functioning. While crying is a symptom, the timing at four days postpartum and the general nature of the woman's feelings point more accurately toward the common blues rather than a major depressive episode.
Choice D rationale
Postpartum psychosis is a psychiatric emergency characterized by a total break from reality, including hallucinations, delusions, and thoughts of harming oneself or the infant. This condition is rare, occurring in about 1 to 2 per 1000 births, and is far more severe than the emotional sensitivity described by the patient. The onset is usually sudden and requires immediate hospitalization to ensure the safety of both the mother and the newborn child.
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
Amenorrhea, or the cessation of menses, is a classic presumptive sign of pregnancy because it is a subjective symptom reported by the patient. While it often indicates conception due to rising progesterone levels maintaining the endometrial lining, it can also be caused by stress, strenuous exercise, or endocrine disorders. Because it is not a definitive objective finding that can only be attributed to a fetus, it remains categorized as a presumptive rather than a probable or positive sign.
Choice B rationale
Breast tenderness is categorized as a presumptive sign because it is a subjective sensation reported by the woman. During early pregnancy, increasing levels of estrogen and progesterone cause vascular engorgement and ductal proliferation within the mammary tissue. While highly suggestive of pregnancy, this symptom can also occur during the luteal phase of the menstrual cycle or due to hormonal medications. Normal physiologic changes in the breasts are among the earliest indicators recognized by the mother.
Choice C rationale
Frequent urination is a presumptive sign of pregnancy because it is a subjective symptom that can be caused by various factors. In the first trimester, the enlarging uterus remains in the pelvic cavity and exerts direct pressure on the bladder, reducing its capacity. However, urinary frequency can also be a symptom of a urinary tract infection, increased fluid intake, or diabetes. Since it is not an exclusive indicator of a developing fetus, it is categorized as presumptive.
Choice D rationale
A positive urine pregnancy test is considered a probable sign of pregnancy rather than a presumptive one. This is because it is an objective laboratory finding that detects human chorionic gonadotropin (hCG). While hCG is primarily produced by the placenta, it can also be present in cases of hydatidiform mole or certain choriocarcinomas. Because the test measures a hormone rather than directly visualizing the fetus, it is not a positive sign, but it is more objective than presumptive signs.
Choice E rationale
Braxton Hicks contractions are categorized as a probable sign of pregnancy. These are painless, irregular contractions that can be felt through the abdominal wall by an examiner starting in the second trimester. They occur as the uterine muscles tighten to enhance blood flow to the placenta. Unlike presumptive signs, these are objective physical findings observed by a healthcare provider. However, they are not positive signs because they do not confirm the presence of a live fetus.
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