The nurse is caring for a client at 8 weeks' gestation who states, "I did not plan for this right now and I am not happy or excited about this pregnancy. I am not sure what to do." Which response by the nurse is best?
"Many pregnant individuals feel this way during the first trimester"
"Do not worry. Once you hold this baby, everything will be fine"
"We can refer you to a clinic for potential termination if you desire"
"You will become excited and happy when you feel the baby move"
The Correct Answer is A
A. "Many pregnant individuals feel this way during the first trimester": This response is appropriate as it normalizes the client's feelings, acknowledging that uncertainty and mixed emotions are common in early pregnancy.
B. "Do not worry. Once you hold this baby, everything will be fine": This response dismisses the client's emotions and assumes a future outcome without offering support or validating their current feelings.
C. "We can refer you to a clinic for potential termination if you desire": While providing options is important, suggesting termination too soon may overwhelm the client without fully understanding their emotional needs.
D. "You will become excited and happy when you feel the baby move": This response assumes the client's future emotional state and does not allow space for the client to process their feelings at their own pace.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Preventing the infant from vomiting: While preventing vomiting is important to avoid putting pressure on the surgical site, it is not the most immediate concern after a cleft lip repair. Postoperative care focuses on protecting the surgical site and preventing trauma to the lip.
B. Keeping the infant in a prone position: The infant should be kept in a position that avoids pressure on the surgical site. In most cases, the infant is kept in a supine or side-lying position to prevent direct pressure on the repair site and promote healing.
C. Preventing crust formation on the suture line: Preventing crust formation is crucial to prevent infection, scarring, or trauma to the surgical repair site and to achieve a good cosmetic outcome. Crusts on the suture line can disrupt healing and should be avoided by gentle cleaning and application of prescribed ointments.
D. Protecting the infant's tongue from swelling: While protecting the infant's tongue is important in general, it is not the primary concern after cleft lip repair. The focus should be on protecting the lip repair site, as this is where the surgical intervention took place.
Correct Answer is B
Explanation
A. G4 T2 P2 A1 L1: The client had one preterm birth at 26 weeks (P1), not two, and the miscarriage counts as an abortion (A1), not as a preterm or term birth. The classification for preterm births should be adjusted to P1, not P2. There is also one term delivery (T1) not two.
B. G4 T1 P1 A1 L1: The client has had 4 pregnancies (G4): one live birth at 38 weeks (T1), one preterm birth at 26 weeks that did not survive (P1), one miscarriage at 8 weeks (A1), and one living child (L1). This is the correct classification.
C. G3 T2 P1 A1 L1: This option is incorrect because the client has had 4 pregnancies, not 3. The correct count should be G4.
D. G3 T2 P1 A2 L1: This option is incorrect because the miscarriage counts as one abortion (A1), not A2, and the client has had 4 pregnancies, not 3. The client has also had one term delivery (T1) not two.
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