When performing an examination of a woman who is 34 weeks pregnant, the nurse notices a midline linear protrusion in the abdomen over the area of the rectus abdominis muscles as the woman raises her head and shoulders off of the bed. Which response by the nurse is correct?

Correct Answer: D

Rationale: In this scenario, the correct response is option D: No correct response provided. This is because the midline linear protrusion noticed by the nurse is likely a normal finding known as diastasis recti, which is the separation of the rectus abdominis muscles along the linea alba. This is a common occurrence during pregnancy due to the stretching of the abdominal muscles to accommodate the growing uterus. Option A is incorrect because diastasis recti is a benign condition that does not typically require documentation unless it is severe or causing discomfort. Option B is incorrect as diastasis recti does not usually require surgical repair unless it is causing significant issues postpartum. Option C is incorrect as the protrusion is more likely due to diastasis recti rather than a hernia caused by increased abdominal pressure. From an educational standpoint, it is important for healthcare providers, especially nurses, to be knowledgeable about common physiological changes that occur during pregnancy. Understanding diastasis recti and differentiating it from more serious conditions like hernias is crucial for accurate assessment and appropriate patient education. By recognizing normal variations, nurses can provide reassurance to pregnant women and help them differentiate between expected changes and potential complications.

Correct Answer: A

Rationale: The normal fetal heart rate falls between 110 and 160 beats per minute, so the nurse should document the results as within the normal range. There is no indication of fetal distress based on the heart rate provided. Verifying with the maternal pulse or having the patient change positions is unnecessary in this scenario.

Correct Answer: C

Rationale: The correct answer is C) Kegel exercises should be performed 50 to 100 times a day. This frequency is recommended to strengthen the pelvic floor muscles, which can help prevent urinary incontinence and support the increasing weight of the uterus during pregnancy. Option A is incorrect because while Kegel exercises do help strengthen pelvic floor muscles, their primary purpose is not to specifically keep the uterus strong during pregnancy. Option B is incorrect as it does not provide a specific frequency for performing Kegel exercises. Twice a day may not be sufficient to achieve the desired strengthening effects on the pelvic floor muscles. Option D is incorrect as it describes the technique of performing Kegel exercises, but it does not address the recommended frequency of performing these exercises. In an educational context, it is important for individuals, especially pregnant women, to understand the correct frequency of performing Kegel exercises to maximize their benefits. By doing Kegel exercises 50 to 100 times a day, individuals can effectively strengthen their pelvic floor muscles, which can contribute to better bladder control, support during pregnancy, and potentially easier labor and delivery.

Correct Answer: B

Rationale: In early pregnancy, complications can arise that require careful planning and consideration when providing care to the client. In this scenario, the correct answer is B) conflict with family over gender expression. This is the most appropriate problem for the nurse to address because conflicts with family over gender expression can significantly impact the emotional well-being and support system of the pregnant individual. It is crucial for the nurse to address and resolve these conflicts to ensure the overall health and safety of both the client and the developing fetus. Option A) conflict with gender identity is not directly related to the immediate care needs of the client in early pregnancy. While gender identity is an important aspect of holistic care, in this specific context, addressing conflicts over gender expression within the family is more urgent and relevant to the client's immediate well-being. Educationally, this question highlights the importance of assessing and addressing psychosocial factors that can impact a pregnant individual's health during early pregnancy. It emphasizes the role of the nurse in providing holistic care that goes beyond just physical health concerns and includes emotional and social support. By understanding and addressing family dynamics and conflicts, nurses can better support their clients through this crucial period in their lives.

Correct Answer: A

Rationale: In this scenario, option A is the correct answer because it demonstrates a trauma-informed and patient-centered approach to addressing intimate partner violence (IPV). By informing the client that it is a policy to screen for safety, the nurse creates a safe space for disclosure and offers help in a non-judgmental manner. This approach respects the client's autonomy while also prioritizing their well-being. Option B is incorrect because it generalizes that abuse is common in pregnant individuals, which can perpetuate stigma and may not apply to every individual. Option C is incorrect as it assumes that individuals hide abusive relationships, which can be a sensitive and potentially triggering assumption to make. Option D is incorrect as it is a judgmental statement that does not facilitate open communication or trust between the nurse and the client. In an educational context, it is essential for healthcare providers to understand the dynamics of IPV, how to approach screening for it sensitively, and the importance of providing support and resources to those experiencing abuse. Nurses play a crucial role in identifying and supporting individuals experiencing IPV, and using a patient-centered approach is key to creating a safe environment for disclosure and intervention.