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

Correct Answer: B

Rationale: Option B is the correct answer because it acknowledges the client's feelings as normal during early pregnancy. It is essential for the nurse to validate the client's emotions and provide reassurance that it is common to have mixed feelings about pregnancy, especially during the first trimester. By normalizing the client's feelings, the nurse can establish a trusting and supportive relationship, which is crucial for effective communication and care. Option A is incorrect because it jumps to informing the provider without first addressing the client's feelings directly. While it is important to involve the provider if necessary, the immediate focus should be on addressing the client's emotions and providing support. Option C is incorrect because it dismisses the client's concerns and puts pressure on them to feel a certain way about their pregnancy. It is not helpful or therapeutic to tell the client how they should be feeling, as this can invalidate their emotions and create additional stress. Option D is incorrect because it assumes that the client needs counseling without first exploring their feelings and offering support. While counseling may be beneficial for some clients, it is important to first address the client's emotions and validate their experiences before making such a recommendation.

Correct Answer: A

Rationale: A: This choice is correct because both caput succedaneum and cephalohematoma are common conditions in newborns due to the pressures of the birth process. Caput succedaneum is a diffuse swelling of the scalp that typically resolves within a few days, while cephalohematoma is a localized collection of blood beneath the periosteum. Both conditions are self-limiting and do not require intervention. B: This choice is incorrect because caput succedaneum appears as a diffuse swelling of the scalp, not a localized area of swelling like cephalohematoma. Cephalohematoma, on the other hand, is a collection of blood beneath the periosteum of the skull and does not involve the soft tissues of the scalp. C: This choice is incorrect because edema that crosses suture lines is actually a characteristic of cephalohematoma, not caput succedaneum. Caput succedaneum is limited to the soft tissues of the scalp and does not cross suture lines. D: This choice is incorrect because bleeding with cephalohematoma occurs between the periosteum and the skull, not just the periosteum alone. The blood collects between the skull bone and the periosteum, causing a distinct swelling that is separate from the scalp tissues.

Correct Answer: B

Rationale: Auscultating the carotid artery is a crucial step in postpartum assessment as it helps to monitor the client's cardiovascular status, especially during the immediate postpartum period when there is an increased risk of hemorrhage. By listening for any abnormal sounds or changes in the pulse, the nurse can quickly identify and intervene in case of any cardiovascular complications. Palpating the breasts is also an essential part of postpartum assessment, as it allows the nurse to check for engorgement, tenderness, or signs of infection. This step is important for assessing the client's breastfeeding experience and providing support and education as needed. However, this action alone does not address the immediate cardiovascular concerns that arise during the postpartum period. Checking vaginal discharge is another important aspect of postpartum assessment, as it helps the nurse monitor for signs of infection, hemorrhage, or other complications related to the delivery. By assessing the color, amount, and odor of the discharge, the nurse can identify any abnormalities and provide appropriate care. However, this step does not directly address the cardiovascular status of the client, which is crucial in the immediate postpartum period. Inspecting the perineum is also a key component of postpartum assessment, as it allows the nurse to assess for any tears, lacerations, or signs of infection that may have occurred during delivery. By checking the perineum, the nurse can provide proper wound care and prevent complications. While this step is important for the client's physical recovery, it does not directly address the cardiovascular status that needs to be monitored closely during the immediate postpartum period. In conclusion, auscultating the carotid artery is the correct action to include in a postpartum assessment on a client who delivered vaginally because it directly addresses the cardiovascular status, which is crucial in the immediate postpartum period. Palpating the breasts, checking vaginal discharge, and inspecting the perineum are also important steps in postpartum assessment but do not directly address the immediate cardiovascular concerns that need to be monitored closely.

Correct Answer: C

Rationale: The correct answer is C: The mother is RH negative, the infant is RH positive. Rhogam is indicated when the mother is Rh negative and the infant is Rh positive. This is because Rh incompatibility occurs when the mother is Rh negative and the infant is Rh positive. If during childbirth or pregnancy, fetal blood enters the maternal circulation, the mother's immune system can produce antibodies against the Rh antigen present in the infant's blood. Rhogam is administered to prevent the mother from forming antibodies against the Rh antigen and potentially harming future pregnancies with Rh positive infants. Choice A is incorrect because both the mother and infant being Rh negative means there is no Rh incompatibility, so Rhogam would not be indicated in this situation. Choice B is incorrect because if the mother is Rh positive and the infant is Rh negative, there is no risk of Rh incompatibility, so Rhogam would not be required. Choice D is incorrect because if both the mother and infant are Rh positive, there is no Rh incompatibility, and Rhogam is not needed. Rhogam is only indicated when the mother is Rh negative and the infant is Rh positive to prevent the mother from forming antibodies against the Rh antigen.

Correct Answer: A

Rationale: Periodic breathing is the correct answer in this scenario. Periodic breathing is a normal respiratory pattern in premature infants where they have short episodes of apnea followed by rapid breathing. In this case, the infant stopping breathing for 20-30 seconds then resuming breathing aligns with the definition of periodic breathing. This pattern is commonly seen in premature infants and usually resolves on its own as the infant matures. Apneic breathing (choice B) refers to a more prolonged cessation of breathing and is not characteristic of the brief episodes seen in periodic breathing. Apneic breathing is a cause for concern and may require intervention to support the infant's breathing. Grunting (choice C) is a sound made by infants during expiration to help keep the lungs inflated. While grunting may be present in infants with respiratory distress syndrome, it does not describe the pattern of breathing observed in this case. Neonatal dyspnea (choice D) refers to difficulty breathing in a newborn, which can present with a variety of symptoms such as grunting, nasal flaring, and retractions. While respiratory distress syndrome can lead to neonatal dyspnea, the specific breathing pattern described in the question is better classified as periodic breathing.