Question

A pregnant client with a history of depression expresses feelings of sadness and anxiety during a prenatal visit. Considering psychosocial factors and therapeutic communication principles, which nursing intervention is the most appropriate first step?

Answer 1

Correct Answers:

Ask open-ended questions to explore the client’s feelings and identify specific stressors.

Rationale :

🟦 The priority first step is therapeutic communication to assess the client’s emotional state using open-ended questions.

🟦 This approach promotes trust, encourages expression, and helps identify specific stressors affecting the pregnancy.

🟦 Early assessment supports timely identification of perinatal depression risk and guides appropriate interventions.

🟦 Exploring feelings also helps determine safety concerns such as worsening depression or suicidal ideation.

🟦 Assessment must occur before reassurance or referral so the plan is based on accurate client needs.

Advise the client to avoid discussing negative feelings to prevent affecting the baby’s development.

🟦 Avoiding discussion blocks emotional support and can worsen untreated depression/anxiety.

🟦 Suppressing feelings prevents accurate assessment and delays necessary care.

Focus immediately on scheduling a referral to a mental health specialist without further assessment.

🟦 Referrals may be needed, but the nurse should first complete assessment to clarify severity and priorities.

🟦 Skipping assessment risks missing urgent safety concerns and client-specific triggers.

Reassure the client that everything will be fine and there is no cause for concern.

🟦 False reassurance minimizes symptoms and discourages disclosure of serious concerns.

🟦 It does not address assessment needs or support evidence-based mental health care.

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Answer 2

Correct Answers:

"We are looking for increases in fetal heart rate of 15/min for at least 15 seconds. This means the baby is doing well."

Rationale :

🟩 A nonstress test evaluates fetal well-being by assessing fetal heart rate accelerations with movement.

🟩 A reactive NST at 32+ weeks shows ≥2 accelerations of 15 bpm lasting 15 seconds within 20 minutes.

🟩 These accelerations indicate an intact fetal nervous system and adequate oxygenation.

🟩 The test is noninvasive and does not assess congenital anomalies or genetic risk directly.

🟩 Explaining the “15 by 15” criterion provides accurate, client-friendly teaching.

“If the baby moves 5 times in 15 minutes, then the baby is healthy.”

🟩 Fetal movement is important, but NST interpretation is based on heart rate accelerations, not a movement count.

🟩 Movement frequency alone does not confirm fetal oxygenation status.

“I am looking at the ultrasound to see if the baby has any congenital anomalies.”

🟩 NST uses external monitoring for fetal heart rate, not a structural ultrasound for anomalies.

🟩 Congenital anomalies are evaluated through targeted ultrasound, not NST criteria.

“We will draw blood to evaluate the baby's risk of genetic problems.”

🟩 NST does not require blood sampling and does not screen for genetic disorders.

🟩 Genetic risk is assessed using maternal labs, screenings, and diagnostic tests like amniocentesis/CVS.

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Answer 3

Correct Answers:

The client is Rh-negative.

Rationale :

🟨 Rho(D) immune globulin is given to prevent Rh sensitization when an Rh-negative client may be exposed to Rh-positive fetal blood.

🟨 Ectopic pregnancy procedures can cause fetomaternal bleeding, increasing sensitization risk.

🟨 Administering Rho(D) protects future pregnancies from hemolytic disease of the newborn.

🟨 The indication is based on the mother’s Rh status, not the amount of blood loss alone.

🟨 For any pregnancy loss/termination/ectopic management, Rh-negative clients typically require prophylaxis.

The client has had significant blood loss during the procedure.

🟨 Blood loss may occur, but Rho(D) is specifically indicated for Rh-negative clients at risk of sensitization.

🟨 Rh status—not surgical blood loss—is the deciding factor for administration.

The client has previously given birth to an Rh-negative infant.

🟨 An Rh-negative infant would not expose the mother to Rh-positive blood.

🟨 The key risk is exposure to Rh-positive fetal cells, not prior Rh-negative births.

The client has expressed a desire to conceive again.

🟨 Future pregnancy plans do not determine need; Rh status and exposure risk do.

🟨 Rho(D) is given to prevent sensitization regardless of stated fertility goals.

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Answer 4

Correct Answers:

G4 T2 P1 A1 L2

Rationale :

🟥 Gravida (G) is total pregnancies, including current: 4.

🟥 Term (T) births are deliveries at ≥37 weeks: 2.

🟥 Preterm (P) births are deliveries between 20–36⁶/₇ weeks: 1.

🟥 Abortions (A) include miscarriage/termination before 20 weeks: 1.

🟥 Living (L) children currently alive: 2, so the correct notation is G4 T2 P1 A1 L2.

G3 T2 P1 A1 L2

🟥 This is incorrect because the client has had 4 total pregnancies, not 3.

🟥 Current pregnancy must be included in gravida count.

G4 T1 P1 A1 L2

🟥 This is incorrect because the client delivered 2 term births, not 1.

🟥 Term births are counted separately from preterm births.

G4 T2 P0 A1 L2

🟥 This is incorrect because the client has 1 preterm birth, not zero.

🟥 Preterm deliveries count even if the infant is not currently living.

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Answer 5

Correct Answers:

"Your age is a risk factor for developing high blood pressure during pregnancy."

Rationale :

🟦 Maternal age 35 and older increases the risk for hypertensive disorders of pregnancy.

🟦 At 37 years, this client is considered advanced maternal age, warranting closer BP monitoring.

🟦 Blood pressure checks support early detection of gestational hypertension and preeclampsia.

🟦 Early identification helps prevent complications such as placental insufficiency and maternal organ dysfunction.

🟦 This response is factual, educational, and addresses the client’s question clearly.

“No need to worry about that, let's talk about how you're feeling.”

🟦 This deflects the question and does not provide health teaching.

🟦 It misses an opportunity to explain the importance of BP monitoring in pregnancy.

“You are at an increased risk for high blood pressure since you've had several pregnancies.”

🟦 Multiple pregnancies are not the primary explanation here; age is the clearer evidence-based risk factor.

🟦 The nurse should provide the most accurate, relevant reason for this client.

“Because blood pressure often increases early in the second trimester of pregnancy.”

🟦 BP typically decreases slightly in early-to-mid pregnancy due to decreased systemic vascular resistance.

🟦 This statement is inaccurate and could misinform the client.

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Answer 6

Correct Answers:

A client who is at 6 weeks of gestation with severe abdominal pain, no bleeding, a blood pressure of 86/58 mm Hg, and a pulse of 132/min

Rationale :

🟩 This client shows signs of shock: severe pain, hypotension, and tachycardia.

🟩 At 6 weeks with severe abdominal pain and unstable vitals, a ruptured ectopic pregnancy is a major concern.

🟩 Hemorrhage can be internal with minimal or no vaginal bleeding, making this a time-critical emergency.

🟩 The nurse must prioritize rapid assessment, IV access, fluid resuscitation, and provider notification.

🟩 Unstable circulation threatens life, making this client the highest priority.

Ectopic pregnancy, BP 128/84, pulse 88, crying

🟩 Emotional distress needs support, but stable vitals indicate lower immediate physiologic threat.

🟩 This client is not showing shock or impending collapse.

8 weeks with moderate vaginal bleeding, minimal pain, BP 118/72, pulse 96

🟩 Vaginal bleeding needs evaluation, but vitals are stable and pain is minimal.

🟩 This is not as urgent as suspected rupture with shock.

9 weeks post methotrexate with moderate pain and dizziness, BP 116/80, pulse 86

🟩 Pain and dizziness warrant assessment, but stable vitals reduce immediate life threat.

🟩 The hypotensive tachycardic client has the most urgent instability.

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Answer 7

Correct Answers:

Ballottement

Rationale :

🟨 Ballottement is a probable sign of pregnancy where the provider feels the fetus rebound after pushing on the cervix.

🟨 It occurs when upward pressure causes the fetus to rise in amniotic fluid and then return to touch the examiner’s fingers.

🟨 This is a clinical finding during pelvic exam, not a client-perceived sensation.

🟨 It supports pregnancy assessment but is not a definitive sign on its own.

🟨 The definition in the question matches ballottement precisely.

Lightening

🟨 Lightening refers to fetal descent into the pelvis later in pregnancy, improving breathing.

🟨 It is not the rebound movement felt during cervical manipulation.

Goodell’s sign

🟨 Goodell’s sign is softening of the cervix in early pregnancy.

🟨 It does not involve fetal movement with pressure.

Chadwick’s sign

🟨 Chadwick’s sign is bluish discoloration of the cervix/vagina due to increased vascularity.

🟨 It is a color change finding, not a movement sensation.

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Answer 8

Correct Answers:

110 to 160/min

Rationale :

🟥 Normal fetal heart rate baseline is 110–160 beats/minute.

🟥 This range reflects expected fetal autonomic balance and oxygenation status.

🟥 Rates persistently above 160 suggest fetal tachycardia, while below 110 suggests bradycardia.

🟥 At 12 weeks, the fetus can have variability, but the accepted normal baseline remains 110–160/min.

🟥 Teaching this range helps the client understand prenatal monitoring and fetal well-being.

80 to 100/min

🟥 This range is too low and would indicate fetal bradycardia.

🟥 Persistent readings here would require urgent evaluation.

160 to 190/min

🟥 This range reflects fetal tachycardia and is not considered normal baseline.

🟥 Sustained rates in this range may indicate infection, dehydration, or fetal distress.

100 to 110/min

🟥 This is borderline low and does not represent the full normal fetal baseline range.

🟥 A baseline near 100 would be concerning if persistent.

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Answer 9

Correct Answers:

"It helps me identify your baby's position in the uterus."

Rationale :

🟦 Leopold maneuvers are used to determine fetal lie, presentation, position, and engagement before auscultating FHR.

🟦 Knowing the baby’s position helps the nurse locate the best spot to hear the fetal heart tones most clearly.

🟦 This assessment supports early recognition of malpresentation (e.g., breech or transverse lie).

🟦 It also guides planning for labor and delivery by identifying whether the fetus is aligned appropriately.

🟦 The most accurate explanation to the client is that palpation helps identify baby’s position in the uterus.

“It helps me determine if you are having contractions.”

🟦 Contractions are assessed by observing/feeling uterine tightening and timing, not primarily by Leopold maneuvers.

🟦 Leopolds focus on fetal position, not contraction pattern assessment.

“It helps me estimate how much your baby currently weighs.”

🟦 Leopolds can suggest size broadly, but they are not a reliable method to estimate fetal weight accurately.

🟦 Ultrasound and fundal height trends are more appropriate for weight estimation.

“It helps me measure how high the top of your uterus is.”

🟦 Fundal height measurement uses a tape measure from symphysis to fundus, not Leopold maneuvers.

🟦 Leopolds are palpation maneuvers aimed at fetal orientation, not uterine height measurement.

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Answer 10

Correct Answers:

Lightening

Rationale :

🟩 Lightening occurs when the fetus descends into the pelvis, usually in the last weeks of pregnancy.

🟩 This reduces pressure on the diaphragm, allowing the client to breathe more easily.

🟩 Clients often report improved breathing but increased pelvic pressure or urinary frequency.

🟩 This is a normal late-pregnancy change that signals the fetus is moving lower.

🟩 The client’s statement strongly matches the physiologic effect of lightening.

Hyperventilation

🟩 Hyperventilation causes decreased CO₂ and symptoms like tingling or dizziness, not improved breathing comfort.

🟩 It would not explain feeling able to breathe “again” from reduced diaphragm pressure.

Decreasing chest diameter

🟩 Chest diameter typically increases to accommodate pregnancy-related respiratory changes.

🟩 A decreasing chest diameter would worsen breathing, not improve it.

Decreased carbon dioxide production

🟩 CO₂ production does not decrease in a way that explains sudden improved breathing late in pregnancy.

🟩 The symptom pattern aligns with fetal descent rather than metabolic CO₂ changes.

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QLexNursing

1 :
A pregnant client with a history of depression expresses feelings of sadness and anxiety during a prenatal visit. Considering psychosocial factors and therapeutic communication principles, which nursing intervention is the most appropriate first step?

2 :
A nurse is assisting with a nonstress test (NST) on a client who is at 36 weeks of gestation and asks "What are you looking for during this test?" Which of the following responses should the nurse make?

3 :
A nurse is caring for a client in the immediate postoperative period following removal of an ectopic pregnancy via salpingostomy. For which of the following indications should the nurse administer Rho(D) immune globulin?

5 :
A nurse is caring for a 37-year-old G4P3 client who is at 14 weeks of gestation. The client asks, "Why are you taking my blood pressure? It's always been normal." Which of the following responses should the nurse make?

6 :
A nurse in the emergency department is caring for a group of clients. Which of the following clients should the nurse plan to see first?

7 :
A nurse is discussing probable signs of pregnancy with a newly licensed nurse. Which of the following terms should the nurse use to describe the movement of the fetus felt by the provider after placing upward pressure on the cervix?

8 :
A nurse is caring for a client who is at 12 weeks of gestation during an initial prenatal visit. The client asks, "What is a normal fetal heart rate?" Which of the following ranges should the nurse provide?

9 :
A nurse is performing Leopold Maneuvers prior to auscultating the fetal heart rate for a client who is at 30 weeks of gestation. The client asks, "Why do you feel around on my belly first?" Which of the following responses should the nurse make?

10 :
A client who is at 39 weeks of gestation tells the nurse, "It has been hard to take a deep breath throughout the pregnancy, but in the past week, I feel like I can breathe again." The nurse should recognize that the client is experiencing the effects of which of the following?

QLexNursing

1 : A pregnant client with a history of depression expresses feelings of sadness and anxiety during a prenatal visit. Considering psychosocial factors and therapeutic communication principles, which nursing intervention is the most appropriate first step?

2 : A nurse is assisting with a nonstress test (NST) on a client who is at 36 weeks of gestation and asks "What are you looking for during this test?" Which of the following responses should the nurse make?

3 : A nurse is caring for a client in the immediate postoperative period following removal of an ectopic pregnancy via salpingostomy. For which of the following indications should the nurse administer Rho(D) immune globulin?

5 : A nurse is caring for a 37-year-old G4P3 client who is at 14 weeks of gestation. The client asks, "Why are you taking my blood pressure? It's always been normal." Which of the following responses should the nurse make?

6 : A nurse in the emergency department is caring for a group of clients. Which of the following clients should the nurse plan to see first?

7 : A nurse is discussing probable signs of pregnancy with a newly licensed nurse. Which of the following terms should the nurse use to describe the movement of the fetus felt by the provider after placing upward pressure on the cervix?

8 : A nurse is caring for a client who is at 12 weeks of gestation during an initial prenatal visit. The client asks, "What is a normal fetal heart rate?" Which of the following ranges should the nurse provide?

9 : A nurse is performing Leopold Maneuvers prior to auscultating the fetal heart rate for a client who is at 30 weeks of gestation. The client asks, "Why do you feel around on my belly first?" Which of the following responses should the nurse make?

10 : A client who is at 39 weeks of gestation tells the nurse, "It has been hard to take a deep breath throughout the pregnancy, but in the past week, I feel like I can breathe again." The nurse should recognize that the client is experiencing the effects of which of the following?

1 :
A pregnant client with a history of depression expresses feelings of sadness and anxiety during a prenatal visit. Considering psychosocial factors and therapeutic communication principles, which nursing intervention is the most appropriate first step?

2 :
A nurse is assisting with a nonstress test (NST) on a client who is at 36 weeks of gestation and asks "What are you looking for during this test?" Which of the following responses should the nurse make?

3 :
A nurse is caring for a client in the immediate postoperative period following removal of an ectopic pregnancy via salpingostomy. For which of the following indications should the nurse administer Rho(D) immune globulin?

5 :
A nurse is caring for a 37-year-old G4P3 client who is at 14 weeks of gestation. The client asks, "Why are you taking my blood pressure? It's always been normal." Which of the following responses should the nurse make?

6 :
A nurse in the emergency department is caring for a group of clients. Which of the following clients should the nurse plan to see first?

7 :
A nurse is discussing probable signs of pregnancy with a newly licensed nurse. Which of the following terms should the nurse use to describe the movement of the fetus felt by the provider after placing upward pressure on the cervix?

8 :
A nurse is caring for a client who is at 12 weeks of gestation during an initial prenatal visit. The client asks, "What is a normal fetal heart rate?" Which of the following ranges should the nurse provide?

9 :
A nurse is performing Leopold Maneuvers prior to auscultating the fetal heart rate for a client who is at 30 weeks of gestation. The client asks, "Why do you feel around on my belly first?" Which of the following responses should the nurse make?

10 :
A client who is at 39 weeks of gestation tells the nurse, "It has been hard to take a deep breath throughout the pregnancy, but in the past week, I feel like I can breathe again." The nurse should recognize that the client is experiencing the effects of which of the following?