Author Question: A 16-year-old pregnant client is seen at her 10-weeks'-gestation visit. She tells the nurse that she ... (Read 65 times)

SGallaher96 · **on:** Jun 27, 2018

A 16-year-old pregnant client is seen at her 10-weeks'-gestation visit. She tells the nurse that she felt the baby move that morning. What response by the nurse is appropriate?

1. That is very exciting. The baby must be very healthy.
2. Would you please describe what you felt for me?
3. That is impossible. The baby is not big enough yet.
4. Would you please let me see whether I can feel the baby?

Question 2

During the fourth stage of labor, the patient's assessment includes a BP of 110/60, pulse 90, and the fundus is firm midline and halfway between the symphysis pubis and the umbilicus. The priority action of the nurse is to:

1. Turn the patient onto her left side.
2. Place the bed in Trendelenburg position.
3. Massage the fundus.
4. Continue to monitor.

sarajane1989 · **Reply #1 on:** Jun 27, 2018

Answer to Question 1

2
Explanation: 2. The nurse should ask the client to describe what she felt, as 10 weeks' gestation is too early to feel fetal movement.

Answer to Question 2

4
Rationale 1: A left lateral position is not necessary with a BP of 110/60 and a pulse of 90.
Rationale 2: The Trendelenburg position is not necessary with a BP of 110/60 and a pulse of 90.
Rationale 3: The uterus should be midline and firm; massage is not necessary.
Rationale 4: The patient's assessment data are normal for the fourth stage of labor, so monitoring is the only action necessary. During the fourth stage of labor, the mother experiences a slight drop in blood pressure and a slightly increased pulse.