A mother has a child who is 4 years of age, and she is expecting another child.The mother expresses concern to the nurse about how the older sibling will receive the newborn.Which intervention shared by the mother would require follow-up by the nurse?
“I plan to let him hear the baby’s heartbeat at the next prenatal visit.”.
“I have enrolled him in a sibling preparation class at the hospital.”.
“I think that I will just bring the new baby home as a surprise.”.
“I let him pick out a gift for the baby, and have one for him from the baby.”.
The Correct Answer is C
Choice A rationale
Allowing the older sibling to hear the baby’s heartbeat at a prenatal visit can help them feel involved and connected to the new baby. This can be a positive experience and does not require follow-up by the nurse.
Choice B rationale
Enrolling the older sibling in a sibling preparation class at the hospital is a good way to prepare them for the arrival of the new baby. These classes often provide valuable information and help older siblings understand what to expect.
Choice C rationale
Bringing the new baby home as a surprise can be problematic. It may cause the older sibling to feel excluded or unprepared for the new addition to the family. It is important to involve the older sibling in the process and prepare them for the changes that will come with the new baby.
Choice D rationale
Allowing the older sibling to pick out a gift for the baby and having a gift for them from the baby can help foster a positive relationship between the siblings. This approach can make the older sibling feel valued and included.
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Correct Answer is ["A","C","D","E"]
Explanation
Choice A rationale
Nausea is a common symptom during pregnancy, especially in the first trimester. It is often referred to as morning sickness, although it can occur at any time of the day. The client’s report of nausea almost every day for the last two months, but lasting for a shorter period of the day, is consistent with typical pregnancy-related nausea.
Choice B rationale
Malodorous vaginal discharge is not a common or expected physiological change during pregnancy. It may indicate an infection or other medical condition that requires further evaluation and treatment.
Choice C rationale
Increased frequency of urination is a common symptom during pregnancy. It occurs due to hormonal changes and the growing uterus putting pressure on the bladder. The client’s report of voiding more frequently without pain is consistent with normal physiological changes during pregnancy.
Choice D rationale
Fundal height measurement is used to assess fetal growth and development. At 18 weeks of gestation, the fundal height is typically around 18 cm, which corresponds to the number of weeks of pregnancy. This finding is consistent with expected physiological changes during pregnancy.
Choice E rationale
The darkened line of skin noted midline on the abdomen, known as the linea nigra, is a common physiological change during pregnancy. It is caused by increased pigmentation and is a normal finding.
Choice F rationale
A dry, reddened patch of skin below the knee bilaterally is not a common or expected physiological change during pregnancy. It may indicate a dermatological condition or other medical issue that requires further evaluation.
Correct Answer is B
Explanation
Choice A rationale
This response is dismissive and does not address the client’s feelings. It may make the client feel invalidated and unsupported.
Choice B rationale
This response acknowledges that ambivalent feelings are common in early pregnancy. It normalizes the client’s feelings and provides reassurance, which is appropriate and supportive.
Choice C rationale
This response imposes an expectation of happiness on the client, which may make her feel guilty or inadequate for not feeling happy. It does not validate her current feelings.
Choice D rationale
This response redirects the client’s feelings to another person (her mother) rather than addressing them directly. It may not be helpful if the client does not have a supportive relationship with her mother.