A 25-year-old gravida 1 para 1 who had an emergency cesarean birth 3 days ago is scheduled for discharge. As the nurse prepares her for discharge, she begins to cry. What action should the nurse take first?
Point out how lucky she is to have a healthy baby
Assess her for pain
Explain that she is experiencing postpartum blues
Allow her time to express her feelings
The Correct Answer is D
Choice A: This is incorrect because pointing out how lucky she is to have a healthy baby may invalidate her feelings and make her feel guilty or ashamed. The nurse should acknowledge and respect the client's emotions and avoid making judgments or comparisons.
Choice B: This is incorrect because assessing her for pain is not the first action that the nurse should take. Although pain may be a factor that contributes to the client's emotional state, it is not the primary cause of her crying. The nurse should first establish rapport and trust with the client and then assess her physical and psychological needs.
Choice C: This is incorrect because explaining that she is experiencing postpartum blues may be premature and inaccurate. Postpartum blues are mild and transient mood changes that occur in up to 80% of women within the first few days after childbirth. They are characterized by tearfulness, irritability, anxiety, and mood swings. However, the nurse should not assume that the client has postpartum blues without performing a thorough assessment and ruling out other possible causes of her crying, such as postpartum depression, anxiety, or trauma.
Choice D: This is the correct answer because allowing her time to express her feelings is the most appropriate and empathetic action that the nurse should take first. The nurse should listen actively and attentively to the client and provide emotional support and reassurance. The nurse should also use open-ended questions and reflective statements to facilitate communication and explore the client's concerns and coping strategies.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice a) Document the event in the nurses' notes is incorrect because this is not a priority action for a neonate who is showing signs of hypoglycemia. Hypoglycemia is a condition where the blood glucose level is lower than normal, which can cause neurological and metabolic problems in newborns. Neonates of diabetic mothers are at higher risk of developing hypoglycemia due to increased insulin production and decreased glycogen stores.
Documenting the event in the nurses' notes is an important step, but it should be done after assessing and treating the neonate's condition.
Choice b) Test for blood glucose level is correct because this is the most important action for a neonate who is exhibiting symptoms of hypoglycemia. The nurse should use a heel stick or a cord blood sample to measure the blood glucose level of the neonate as soon as possible, as hypoglycemia can lead to serious complications such as seizures, coma, brain damage, or death if left untreated. The normal blood glucose range for a full-term neonate is 40 to 60 mg/dL in the first hour of life, and 50 to 90 mg/dL thereafter. A blood glucose level below 40 mg/dL indicates hypoglycemia and requires immediate intervention.
Choice c) Notify the clinician stat is incorrect because this is not the most urgent action for a neonate who is suffering from hypoglycemia. The nurse should notify the clinician after confirming the diagnosis of hypoglycemia and initiating treatment, such as feeding or administering intravenous glucose. The clinician may order further tests or treatments depending on the severity and cause of the hypoglycemia, but the nurse should not delay the initial management of the neonate's condition.
Choice d) Start an intravenous line with D5W is incorrect because this is not the first-line treatment for a neonate who has hypoglycemia. D5W stands for dextrose 5% in water, which is a solution that contains glucose and water. It can be used to treat hypoglycemia by providing a source of energy and fluid to the neonate. However, before starting an intravenous line with D5W, the nurse should first attempt to feed the neonate with breast milk or formula, as this can also raise the blood glucose level and provide other nutrients and antibodies. If feeding is unsuccessful or contraindicated, then the nurse should start an intravenous line with D5W as ordered by the clinician.
Correct Answer is A
Explanation
Choice a) This could result in profound bleeding is correct because this is the primary reason why an internal examination should be avoided for a client who has placenta previa. Placenta previa is a condition where the placenta covers part or all of the cervix, preventing normal delivery. An internal examination involves inserting a gloved finger or a speculum into the vagina and cervix to assess their dilation, effacement, position, and station. This can cause trauma to the cervix or the placenta, which can trigger severe hemorrhage and endanger the mother and the fetus. Therefore, this explanation is accurate and appropriate.
Choice b) This could initiate preterm labor is incorrect because this is not the main reason why an internal examination should be avoided for a client who has placenta previa. Placenta previa is a condition where the placenta covers part or all of the cervix, preventing normal delivery. An internal examination may stimulate uterine contractions, which can lead to preterm labor and delivery. However, this is not the most serious or likely complication of an internal examination for a client who has placenta previa, as the bleeding risk is much higher and more urgent. Therefore, this explanation is incomplete and misleading.
Choice c) There is an increased risk of introducing infection is incorrect because this is not a specific reason why an internal examination should be avoided for a client who has placenta previa. Placenta previa is a condition where the placenta covers part or all of the cervix, preventing normal delivery. An internal examination may introduce bacteria or other microorganisms into the vagina or cervix, which can cause infection and inflammation. However, this is a general risk that applies to any pregnant woman who undergoes an internal examination, not just those who have placenta previa. Therefore, this explanation is irrelevant and inaccurate.
Choice d) There is an increased risk of rupture of the membranes is incorrect because this is not a relevant reason why an internal examination should be avoided for a client who has placenta previa. Placenta previa is a condition where the placenta covers part or all of the cervix, preventing normal delivery. An internal examination may cause rupture of the membranes, which are the sacs that contain the amniotic fluid and the fetus. However, this is not a significant or common complication of an internal examination for a client who has placenta previa, as the membranes are usually located above or away from the placenta and cervix. Therefore, this explanation is improbable and inaccurate.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today