The nurse in a prenatal clinic is assessing a patient who is at 37 weeks' gestation for twins. The patient reports increased discomfort and increased lower pelvic pressure.
Which action does the nurse take with this patient?
Explains to the patient that increased discomfort is expected with twins.
Performs a digital cervical examination to determine if dilation is occurring.
Sends the patient to the hospital to be checked for possible signs of labor.
After examination, assures the patient of the absence of contractions.
The Correct Answer is C
Choice A rationale
While it’s true that increased discomfort is expected with twins due to additional physical strain and space constraints, this alone is not sufficient reassurance. It is vital to assess for
signs of preterm labor or other complications.
Choice B rationale
Performing a digital cervical examination is a valid approach to checking for dilation, but this action must be carefully considered based on other signs and symptoms presented by
the patient. The focus here is on ensuring the absence or presence of labor, which might require hospital assessment.
Choice C rationale
Sending the patient to the hospital to be checked for possible signs of labor ensures that professional monitoring and interventions can occur if labor is confirmed. This action
prioritizes safety, given the increased risk of complications with twin pregnancies and the advanced gestation of 37 weeks.
Choice D rationale
Assuring the patient of the absence of contractions after an examination might provide temporary relief, but it does not address the possibility of other signs of labor or complications
that may require more comprehensive hospital assessment.
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Correct Answer is D
Explanation
Choice A rationale
Placing a pacifier in the baby's mouth is inappropriate because it does not address the underlying cause of grunting, which can be a sign of respiratory distress.
Choice B rationale
Checking the baby's diaper is not relevant to assessing the cause of grunting. Grunting is usually related to respiratory issues rather than a dirty diaper.
Choice C rationale
Having the mother feed the baby is inappropriate because grunting may indicate respiratory distress. Feeding should be deferred until the baby's respiratory status is assessed and stabilized.
Choice D rationale
Assessing the respiratory rate is appropriate because grunting in a newborn can indicate respiratory distress. The nurse should evaluate the respiratory status to determine the need for further intervention.
Correct Answer is B
Explanation
Choice A rationale
Decreased muscle tone is not typically associated with NAS. NAS often presents with increased muscle tone due to withdrawal symptoms.
Choice B rationale
A continuous high-pitched cry is a hallmark sign of NAS, indicating withdrawal and discomfort. This is due to overstimulation of the central nervous system.
Choice C rationale
Newborns with NAS often have difficulty sleeping due to irritability and discomfort, sleeping for shorter periods.
Choice D rationale
Tremors in NAS are typically pronounced and continuous, not just when disturbed. These tremors result from withdrawal effects on the nervous system.