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 A
Explanation
Choice A) Spending extra time holding and rocking the infant is correct because this is an effective and recommended nursing care for an infant with neonatal abstinence syndrome. Neonatal abstinence syndrome (NAS) is a condition that occurs when an infant is exposed to drugs such as opioids, cocaine, or alcohol in utero and goes through withdrawal after birth. NAS can cause various physical and behavioral problems in the infant, such as irritability, poor feeding, vomiting, diarrhea, sweating, fever, or seizures. Holding and rocking the infant can provide comfort, warmth, and security to the infant, as well as reduce stress and pain. It can also promote bonding and attachment between the infant and the caregiver. Therefore, this nursing care should be included in the care plan for an infant with NAS.
Choice B) Feeding the infant on a 2-hour schedule is incorrect because this is not a helpful or appropriate nursing care for an infant with neonatal abstinence syndrome. Feeding is an important aspect of caring for any infant, as it provides nutrients and calories that support growth and development. However, feeding an infant with NAS on a 2- hour schedule may not be suitable or feasible, as NAS can affect the infant's feeding ability and tolerance. An infant with NAS may have difficulty sucking, swallowing, or coordinating breathing during feeding. They may also have frequent vomiting, diarrhea, or dehydration that can interfere with feeding. Therefore, feeding an infant with NAS should be done according to their cues and needs, rather than a fixed schedule. The infant should be offered small, frequent feedings of breast milk or formula, depending on the mother's preference and availability. The infant should also be burped often and held upright after feeding to prevent aspiration or reflux.
Choice C) Positioning the infant's crib in a quiet corner of the nursery is incorrect because this is not a sufficient or optimal nursing care for an infant with neonatal abstinence syndrome. Positioning is an important aspect of caring for any infant, as it affects their comfort, safety, and development. However, positioning an infant with NAS in a quiet corner of the nursery may not be enough or beneficial, as NAS can make the infant more sensitive and responsive to environmental stimuli. An infant with NAS may be easily disturbed or overstimulated by noise, light, or movement in the nursery. They may also feel isolated or neglected if they are placed away from other infants or caregivers.
Therefore, positioning an infant with NAS should be done in a way that minimizes stimulation and maximizes interaction. The crib should be placed in a dimly lit, low noise area of the nursery, but close enough to allow frequent monitoring and contact by the nurse. The crib should also be padded with soft blankets or pillows to prevent injury from excessive movements or seizures.
Choice D) Placing stuffed animals and mobiles in the crib to provide visual stimulation is incorrect because this is not a safe or suitable nursing care for an infant with neonatal abstinence syndrome. Stimulation is an important aspect of caring for any infant, as it enhances their learning and development. However, stimulating an infant with NAS with stuffed animals and mobiles may not be appropriate or advisable, as NAS can make the infant more irritable and restless. An infant with NAS may not enjoy or tolerate visual stimulation from toys or objects in their crib. They may also become agitated or overexcited by them, which can worsen their symptoms or cause complications. Moreover, placing stuffed animals and mobiles in the crib can pose a risk of suffocation, strangulation, or injury for the infant. Therefore, stimulating an infant with NAS should be done in a way that is gentle and gradual. The nurse should use soothing techniques such as talking softly, singing lullabies, or massaging the infant's skin to calm them down. The nurse should also use simple toys such as rattles or balls to engage them in play when they are alert and interested.
Correct Answer is D
Explanation
Choice a) Ectopic pregnancy is incorrect because this is not a condition that requires delivery by cesarean section. Ectopic pregnancy is a condition where the fertilized egg implants outside the uterus, usually in the fallopian tube. It is a life-threatening complication that can cause internal bleeding and rupture of the tube. Ectopic pregnancy cannot result in a viable baby and must be terminated as soon as possible, either by medication or surgery. Therefore, this response is irrelevant and inaccurate.
Choice b) Preeclampsia is incorrect because this is not a condition that always necessitates delivery by cesarean section. Preeclampsia is a condition where the blood pressure rises above 140/90 mmHg after 20 weeks of pregnancy, along with proteinuria and edema. It can cause complications such as eclampsia, HELLP syndrome, placental abruption, and fetal growth restriction. The only cure for preeclampsia is delivery of the baby and placenta, but the mode of delivery depends on several factors, such as the gestational age, the severity of the condition, the fetal status, and the maternal preference. Therefore, some women with preeclampsia may deliver vaginally, while
others may need a cesarean section.
Choice c) Partial abruptio placentae is incorrect because this is not a condition that always necessitates delivery by cesarean section. Abruptio placentae is a condition where the placenta separates from the uterine wall before delivery, causing vaginal bleeding, abdominal pain, uterine contractions, and fetal distress. It can be classified as partial or complete, depending on the extent of the separation. The mode of delivery for abruptio placentae depends on several factors, such as the degree of bleeding, the fetal viability, the cervical dilation, and the fetal position.
Therefore, some women with partial abruptio placentae may deliver vaginally, while others may need a cesarean section.
Choice d) Total placenta previa is correct because this is the only condition that always necessitates delivery by cesarean section. Placenta previa is a condition where the placenta covers part or all of the cervix, preventing normal delivery. It can be classified as marginal, partial, or total, depending on the degree of overlap. The mode of delivery for placenta previa depends on several factors, such as the type of previa, the amount of bleeding, the gestational age, and the fetal status. However, women with total placenta previa have no chance of delivering vaginally, as the placenta completely blocks the birth canal. Therefore, they must have a cesarean section to avoid hemorrhage and fetal compromise.
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