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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is D
Explanation
Choice A rationale
A temperature of 37.8°C (100°F) 18 hours postpartum is slightly elevated but not necessarily indicative of a serious issue. It may require monitoring but is not the most urgent concern.
Choice B rationale
Abdominal pain during breastfeeding 8 hours postpartum is a common experience due to uterine contractions. While it may cause discomfort, it is not typically an urgent concern.
Choice C rationale
Not having a bowel movement 24 hours postpartum is not uncommon and does not usually require immediate attention. It can be addressed with dietary changes and other interventions.
Choice D rationale
Saturating one perineal pad over 2 hours 6 hours postpartum in a G5P4 client indicates a potential risk of postpartum hemorrhage. This is a more urgent concern that requires immediate assessment and intervention to prevent complications.
Correct Answer is D
Explanation
Choice A rationale
Serum bilirubin is not the priority test for hyperemesis gravidarum. It is more relevant for assessing liver function and jaundice.
Choice B rationale
Liver enzymes may be elevated in hyperemesis gravidarum, but they are not the priority test. The primary concern is dehydration and electrolyte imbalance.
Choice C rationale
A CBC can provide information on the client’s overall health, but it is not the priority test for hyperemesis gravidarum. The focus should be on assessing hydration status.
Choice D rationale
Urinalysis for ketones is the priority test because it helps assess the severity of dehydration and malnutrition. The presence of ketones indicates that the body is breaking down fat for energy, which is a sign of inadequate caloric intake.