The clinic nurse is caring for a client at 31 weeks gestation who is scheduled for induction of labor at 42 weeks gestation.
Which teaching is a priority for this client?
Methods of labor induction.
Benefits of breastfeeding.
Signs of labor.
Monitoring of fetal movement.
The Correct Answer is D
Choice A rationale
While understanding methods of labor induction is important if the pregnancy progresses to 42 weeks, it is not the priority teaching at 31 weeks gestation. The immediate focus should be on recognizing potential complications that could arise before the scheduled induction.
Choice B rationale
The benefits of breastfeeding are important for all pregnant women but are not the priority teaching for a client at 31 weeks who is not yet in labor. Information about breastfeeding can be provided later in the pregnancy.
Choice C rationale
Teaching the signs of labor is important as the client approaches term, but at 31 weeks, the priority is to educate the client on recognizing potential warning signs that require immediate attention, such as decreased fetal movement.
Choice D rationale
Monitoring fetal movement is a crucial teaching point at 31 weeks gestation. A decrease in fetal movement can be an early indicator of fetal compromise and requires prompt evaluation. Instructing the client on how to perform kick counts and when to report changes is a priority for ensuring fetal well-being before the scheduled induction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Elevating the mother's legs may help with venous return and circulation, but it does not directly address a soft and boggy uterus, which indicates uterine atony and a risk for hemorrhage. The immediate priority is to promote uterine contraction.
Choice B rationale
A soft and boggy uterus indicates uterine atony, a primary cause of postpartum hemorrhage. Massaging the fundus stimulates the uterine muscles to contract, which helps to compress the blood vessels at the placental site and reduce bleeding. This is the most appropriate initial intervention to address uterine atony.
Choice C rationale
Encouraging the mother to void is important in the postpartum period as a full bladder can displace the uterus and interfere with its ability to contract. However, in the presence of a soft and boggy uterus, the immediate priority is to directly stimulate uterine contraction through fundal massage before addressing bladder emptying.
Choice D rationale
Pushing on the uterus to express clots without first ensuring the uterus is firm is contraindicated. A soft, atonic uterus is more susceptible to inversion if pressure is applied. Fundal massage should be performed first to encourage uterine contraction and firmness before attempting to express any clots.
Correct Answer is A
Explanation
Choice A rationale
Postpartum blues are characterized by labile mood, tearfulness, anxiety, and irritability that typically peak around the third to fifth postpartum day and resolve within two weeks. These feelings are often attributed to hormonal shifts, psychological adjustments, and fatigue experienced after childbirth. The woman's statement of feeling "let down" and crying for no reason, occurring on the fourth postpartum day, aligns with the typical presentation of postpartum blues.
Choice B rationale
Postpartum depression (PPD) involves more intense and persistent symptoms than postpartum blues, including depressed mood, loss of interest or pleasure, changes in appetite and sleep, fatigue, feelings of worthlessness or guilt, and difficulty concentrating. These symptoms typically last longer than two weeks and interfere with daily functioning. The woman's statement alone does not provide enough information to diagnose PPD.
Choice C rationale
Postpartum delirium is a rare but serious psychiatric emergency characterized by rapid onset of confusion, disorientation, hallucinations, delusions, and agitation. It typically occurs within the first few days postpartum. The woman's description of her feelings does not suggest the presence of delirium.
Choice D rationale
Attachment difficulty refers to challenges in forming a secure emotional bond between the mother and her infant. While the woman expresses loving her son, her emotional state of feeling "let down" and crying is not a direct indicator of attachment difficulties, which manifest as a lack of engagement or negative interactions with the baby.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.