A nurse is collecting data from a client who is at 23 weeks of gestation.Which of the following client statements should the nurse identify as a potential psychosocial concern?
“I’ve started to purchase furniture for the baby’s room.”.
“I’m not sure if I want an epidural during labor.”.
“My partner is planning to attend birthing classes with me.”.
“I’m not sure my older child will accept the new baby.”.
The Correct Answer is D
Choice A rationale
Purchasing furniture for the baby’s room is a common and healthy behavior during pregnancy. It indicates that the client is preparing for the baby’s arrival and is excited about the new addition to the family. This behavior is generally seen as positive and supportive of the pregnancy.
Choice B rationale
Being unsure about wanting an epidural during labor is a normal concern for many pregnant individuals. It reflects the client’s consideration of pain management options and their desire to make an informed decision. This is not typically seen as a psychosocial concern.
Choice C rationale
The partner planning to attend birthing classes with the client is a positive sign of support and involvement in the pregnancy. It indicates that the partner is engaged and willing to participate in the childbirth process, which can be beneficial for the client’s emotional well-being.
Choice D rationale
Expressing uncertainty about whether an older child will accept the new baby can indicate underlying anxiety or stress about family dynamics and the impact of the new baby on existing relationships. This concern may require further exploration and support to ensure the client’s emotional health.
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Correct Answer is D
Explanation
Choice A rationale
White blood cell count is not an indicator of anemia. It measures immune function and can indicate infection or inflammation.
Choice B rationale
Urine specific gravity does not identify the risk for pregnancy-induced hypertension. It measures the concentration of urine and can indicate hydration status.
Choice C rationale
Sedimentation rate does not check for signs of cancer. It measures inflammation in the body and can indicate various conditions.
Choice D rationale
Platelet count identifies if the client is at risk for bleeding. Low platelet levels can indicate a higher risk of bleeding and are important to monitor during pregnancy.
Correct Answer is D
Explanation
Choice A rationale
Administering oxygen may help with symptoms like headache and weakness, but it does not address the underlying issue of poor circulation and potential shock. Elevating the legs is more effective in improving blood flow to vital organs.
Choice B rationale
Offering an ice pack is not appropriate for the symptoms described. The client is showing signs of shock, and an ice pack would not address the underlying issue.
Choice C rationale
Providing a warm blanket may offer comfort, but it does not address the symptoms of shock. Elevating the legs is a more direct intervention to improve circulation and stabilize the client.
Choice D rationale
Elevating the client’s legs helps improve venous return to the heart, increasing cardiac output and stabilizing blood pressure. This is a critical intervention for a client showing signs of shock.