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 D
Explanation
A. Abdominal discomfort: While burping can help relieve some discomfort after feeding, the primary concern following pyloric stenosis surgery is avoiding pressure on the incision line, rather than just abdominal discomfort.
B. Intestinal obstruction: Burping after feedings can help reduce the buildup of air in the stomach, but it is not directly aimed at preventing intestinal obstruction. Obstruction is more related to the surgical site and healing process, not the burping.
C. Contaminating flatulence: Flatulence is not a concern related to burping after pyloric stenosis surgery. Burping is done to release air swallowed during feeding, not to manage flatulence.
D. Pressure on the incision line: Burping helps to release any air swallowed during feeding, reducing abdominal distention and minimizing pressure on the surgical site. This is important to ensure proper healing and comfort after the procedure.
Correct Answer is C
Explanation
A. Prevention of oral infection: While oral infection prevention is important, the main concern for a newborn with cleft lip and palate is ensuring proper nutrition. Difficulty with feeding due to the cleft requires immediate intervention to ensure adequate nourishment before surgery.
B. Visual stimulation: Visual stimulation is beneficial for infant development but is not the primary focus in preoperative care for a newborn with a cleft lip and palate. The priority is addressing feeding challenges that affect the baby’s nutritional intake.
C. Nutrition: Infants with cleft lip and palate often struggle with feeding, making proper nutrition the most critical concern. Special feeding techniques are needed to ensure the infant receives enough nourishment before surgery to promote growth and health.
D. Prevention of pneumonia: Although preventing pneumonia is essential, the immediate focus for a newborn with cleft lip and palate is ensuring adequate nutrition. Nutritional support is necessary to maintain overall health and reduce the risk of complications, including pneumonia.
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