Author Question: The nurse is interviewing a client who is 36 weeks pregnant. Which client statement would require ... (Read 46 times)

cherise1989 · **on:** Jun 25, 2018

The nurse is interviewing a client who is 36 weeks pregnant. Which client statement would require immediate intervention by the nurse?

1. I have to get up during the night to void.
2. I have not felt the baby move today.
3. I am leaking a yellowish fluid from my breasts.
4. I have been taking Tylenol (acetaminophen) for my backaches.

Question 2

The nurse is interviewing a primigravida client who is 17 weeks pregnant. During the data collection the client reports she has not felt the baby move yet. Which response by the nurse is the most appropriate?

1. We will listen for the heartbeat today.
2. You need an ultrasound.
3. Fetal movement may not be felt until the 18th week.
4. Do you have reason to believe your baby is not ok?

micaelaswann · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Correct Answer: 2
The absence or change in fetal movement can signal a problem with the pregnancy. When no fetal movement has been noted in the past 8 hours, there are fewer than 10 movements in 12 hours, there is a change in the usual pattern of movements, or a sudden increase in violent fetal movements followed by a complete cessation of movement, further investigation is warranted. Immediate evaluation of the fetus should take place. Urinary frequency is common during the last months of pregnancy as the uterus places pressure on the bladder. Pregnant women begin to produce and secrete colostrum from the breasts during pregnancy. Tylenol is appropriate for the back pain that accompanies third trimester pregnancy.

Answer to Question 2

Correct Answer: 3
Quickening, the fluttery initial sensations of fetal movement perceived by the mother, usually occurs at approximately 18 weeks, possibly earlier in women who have given birth before. This mother is in need of factual information from the nurse. While all prenatal care appointments at this gestation and beyond will include an assessment of the fetal heartbeat, this option does not meet the client's need for education. Ultrasounds may be performed to assess for fetal viability but there is no indication at this time the pregnancy is at risk. Asking if the client is feeling uneasy about the health of the pregnancy does not meet the client's need for information.