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) Antihypertensive: This is not the correct classification of magnesium sulfate. Antihypertensives are drugs that lower blood pressure, such as beta blockers, calcium channel blockers, or angiotensin-converting enzyme inhibitors. Magnesium sulfate does not have a significant effect on blood pressure, and it is not used as a primary treatment for hypertension in preeclampsia.
Choice B) Anticonvulsant: This is the correct classification of magnesium sulfate. Anticonvulsants are drugs that prevent or reduce the frequency and severity of seizures, such as phenytoin, valproic acid, or carbamazepine.
Magnesium sulfate is used as a prophylactic and therapeutic agent for eclampsia, which is a life-threatening complication of preeclampsia characterized by seizures. Magnesium sulfate acts by blocking the neuromuscular transmission and reducing the cerebral edema and vasospasm.
Choice C) Tocolytic: This is not the correct classification of magnesium sulfate. Tocolytics are drugs that inhibit uterine contractions and delay preterm labor, such as terbutaline, nifedipine, or indomethacin. Magnesium sulfate is not effective as a tocolytic agent, and it is not recommended for this purpose by the American College of Obstetricians and Gynecologists.
Choice D) Diuretic: This is not the correct classification of magnesium sulfate. Diuretics are drugs that increase urine output and reduce fluid retention, such as furosemide, hydrochlorothiazide, or spironolactone. Magnesium sulfate does not have a diuretic effect, and it can cause fluid overload and pulmonary edema if administered in excess.
Correct Answer is B
Explanation
Choice A) Increased urinary output: This is not a sign of sepsis in newborns. In fact, sepsis can cause reduced urinary output due to poor blood flow to the kidneys and dehydration.
Choice B) Hypothermia: This is a sign of sepsis in newborns. Sepsis can cause changes in temperature, often fever, but sometimes low temperature. Hypothermia can indicate a severe infection that affects the body's ability to regulate its temperature.
Choice C) Wakefulness: This is not a sign of sepsis in newborns. Sepsis can cause reduced activity and lethargy due to inflammation and organ dysfunction.
Choice D) Interest in feeding: This is not a sign of sepsis in newborns. Sepsis can cause reduced sucking and difficulty feeding due to poor appetite, nausea, vomiting, and abdominal distension.
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