A primipara at 38-weeks gestation is admitted to labor and delivery for a biophysical profile (BPP). The nurse should prepare the client for what procedures?

Correct Answer: C

Rationale: The correct answer is C: Ultrasonography and nonstress test. At 38 weeks gestation, a biophysical profile (BPP) is typically done to assess fetal well-being. Ultrasonography is used to evaluate fetal movements, tone, breathing movements, and amniotic fluid volume. The nonstress test assesses fetal heart rate in response to fetal movement, indicating fetal well-being. Chorionic villus sampling (A) and amniocentesis (B) are invasive procedures not typically done as part of a routine BPP. Oxytocin challenge test (D) is not indicated in this scenario as it is used to assess placental function in high-risk pregnancies.

Correct Answer: D

Rationale: The correct answer is D because the nurse's silence allows the client to reflect on and process their emotions after expressing uncertainty about the future. By remaining silent, the nurse gives the client space to explore their feelings and thoughts without interruption. This can help the client gain insight and come to terms with their emotions. A: The nurse's silence does not indicate disapproval, as it is a common therapeutic technique. B: While the nurse may be showing respect for the client's loss, the primary reason for the silence is to facilitate the client's reflection. C: Although silence can sometimes mirror the client's emotions, the main purpose here is to enable contemplation rather than direct mirroring.

Correct Answer: B

Rationale: The correct answer is B because the client delivered a 7-pound infant 12 hours ago and is now experiencing a severe headache, which could indicate postpartum preeclampsia. Checking if the client received anesthesia during delivery is crucial as certain types of anesthesia can increase the risk of postpartum preeclampsia. This step is important to determine if anesthesia is a contributing factor to the client's symptoms. Option A is incorrect because immediate action is needed to address the client's symptoms related to anesthesia. Option C is incorrect as reassessing vital signs alone may not provide information specific to the client's headache. Option D is incorrect as obtaining a hemoglobin and hematocrit would not directly address the client's headache or potential anesthesia-related issues.

Correct Answer: A

Rationale: The correct answer is A: Administer the albuterol inhaler before other inhaled medications. Administering albuterol first helps open airways, allowing better absorption of subsequent medications. Option B does not directly enhance medication efficacy. Option C promotes hydration but doesn't affect medication efficacy. Option D does not specifically enhance medication therapy.

Correct Answer: C

Rationale: The correct answer is C because sitting with the client and offering support without demanding participation is crucial in building trust and rapport. This approach respects the client's autonomy and allows them to feel supported without pressure. It also creates a safe space for the client to open up when they are ready. Explanation for why the other choices are incorrect: A: Offering high-calorie snacks and frequent small meals does not address the core issue of the client's refusal to participate in therapy. B: Asking the client why they are not participating in therapy may come off as confrontational and could further discourage them from opening up. D: Encouraging the client to discuss their feelings of hopelessness may be overwhelming for them at this stage and could lead to resistance.