A woman is 16 weeks pregnant. She has had cramping, backache, and mild bleeding for the past 3 days. Her physician determines that her cervix is dilated to 2 centimeters, with 10% effacement, but membranes are still intact
She is crying, and says to the nurse, "Is my baby going to be okay?" In addition to acknowledging the client's fear, the nurse should also say: 1. "Your baby will be fine. We'll start IV, and get this stopped in no time at all."
2. "Your cervix is beginning to dilate. That is a serious sign. We will continue to monitor you and the baby for now."
3. "You are going to miscarry. But you should be relieved, because most miscarriages are the result of abnormalities in the fetus."
4. "I really can't say. However, when your physician comes, I'll ask her to talk to you about it."
2
Rationale:
1. This is a serious situation. The client should not be offered false hope of everything being fine.
2. A cerclage can be performed in the first trimester and early into the second trimester. Many interventions can be attempted to prevent further dilation and effacement.
3. The nurse should avoid justification of the miscarriage.
4. The nurse should not defer the conversation to someone else (i.e., the physician).
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