A client who is at 8 weeks of gestation tells the nurse, 'I am not sure I am happy about being pregnant.' Which of the following responses should the nurse make?

Correct Answer: B

Rationale: Rationale for Correct Answer B: It is normal to have these feelings during the first few months of pregnancy. 1. Acknowledges client's emotions without judgment. 2. Validates the client's experience as common and normal. 3. Provides reassurance and support. 4. Encourages open communication. Summary of Incorrect Choices: A. Not necessary to escalate without client's consent. C. Invalidates client's feelings and imposes expectations. D. Implies assumption of severity and may be seen as intrusive.

Correct Answer: B

Rationale: The correct answer is B: Transition. Transition phase occurs when the cervix is dilated from 8 to 10 cm. This phase is characterized by intense contractions close together, increased rectal pressure, and emotional changes. The client in this scenario has contractions 2 to 3 minutes apart, lasting 80 to 90 seconds, and the cervix is dilated to 9 cm. This aligns with the characteristics of the transition phase. Summary: A: Active phase occurs when the cervix is dilated from 4 to 7 cm. C: Latent phase occurs when the cervix is dilated from 0 to 3 cm. D: Descent phase is not a recognized phase of labor.

Correct Answer: D

Rationale: The correct answer is D: Neural tube defects. Folic acid is crucial for neural tube development in the fetus. Without sufficient folic acid, neural tube defects like spina bifida can occur. Iron deficiency anemia (A) is not directly related to folic acid deficiency. Poor bone formation (B) is more associated with calcium and vitamin D deficiencies. Macrosomic fetus (C) refers to excessive fetal growth, not a direct consequence of folic acid deficiency. In summary, folic acid deficiency primarily increases the risk of neural tube defects in the fetus or neonate.

Correct Answer: B

Rationale: Rationale for Correct Answer B: It is normal to have these feelings during the first few months of pregnancy. 1. Acknowledges client's emotions without judgment. 2. Validates the client's experience as common and normal. 3. Provides reassurance and support. 4. Encourages open communication. Summary of Incorrect Choices: A. Not necessary to escalate without client's consent. C. Invalidates client's feelings and imposes expectations. D. Implies assumption of severity and may be seen as intrusive.

Correct Answer: A

Rationale: The correct answer is A: The client's room number. Using the client's room number as a secondary identifier is not appropriate as it does not uniquely identify the client and can lead to errors. The room number may change, or there could be multiple clients in the same room. Telephone number, birth date, and medical record number are more reliable secondary identifiers as they are unique to the client and less likely to be confused with another individual. It is essential to use accurate and reliable identifiers to ensure patient safety and prevent medication errors.

Correct Answer: B

Rationale: The correct answer is B. The blotchy hyperpigmentation on the client's forehead is likely melasma, a common occurrence during pregnancy. This is due to hormonal changes causing increased melanin production. The nurse should educate the client that this is an expected occurrence during pregnancy and reassure her that it is usually temporary and will fade postpartum. Choice A (Tell the client to follow up with a dermatologist) is incorrect because dermatological consultation is not typically necessary for melasma during pregnancy. Choice C (Instruct the client to increase her intake of vitamin D) is incorrect because vitamin D deficiency is not typically associated with blotchy hyperpigmentation on the forehead during pregnancy. Choice D (Inform the client she might have an allergy to her skin care products) is incorrect because melasma is not caused by allergies to skincare products.

Correct Answer: D

Rationale: The correct answer is D because it is important to stop suctioning when the newborn's cry sounds clear to avoid causing unnecessary discomfort or injury. Step 1: Gently compress the bulb syringe. Step 2: Insert the tip into the nostril, not the mouth. Step 3: Release the bulb to suction out the secretions. Step 4: Repeat in the other nostril. Incorrect choices: A is incorrect because you should insert the syringe tip before compressing the bulb. B is incorrect as you should suction the mouth before the nose. C is incorrect as you should not insert the syringe tip in the center of the mouth.

Correct Answer: A

Rationale: The correct answer is A: Hypertension. Carboprost is a prostaglandin used to treat postpartum hemorrhage that can cause hypertension as an adverse effect due to its vasoconstrictive properties. This can lead to increased blood pressure, which should be monitored closely. Hypothermia (choice B) is not a common adverse effect of carboprost. Constipation (choice C) and muscle weakness (choice D) are also not typically associated with carboprost use. Monitoring blood pressure and signs of hypertension is crucial due to the potential adverse effects of carboprost.

Correct Answer: D

Rationale: The correct answer is D: Keep a daily record of fetal kick counts. This is important for monitoring fetal well-being, especially in cases of premature rupture of membranes. By counting fetal kicks daily, the client can assess fetal movements and report any changes promptly to healthcare providers. This helps in early detection of fetal distress or problems. A: Using a condom with sexual intercourse is not relevant to the situation of premature rupture of membranes. B: Avoiding bubble bath solution is important for preventing vaginal infections but not directly related to monitoring fetal well-being. C: Wiping from front to back during perineal hygiene is a general hygiene practice and not specific to the situation of premature rupture of membranes.