A nurse is assisting with the admission of a client who is Hispanic to the labor and delivery unit. Which of the following practices should the nurse anticipate while caring for this client? (Select onE.:
Absence of family members during labor
Request to drink cold fluids immediately after delivery
Practice of maternal fasting following the birth
Desire to delay breastfeeding for several days
The Correct Answer is D
Choice A: Absence of family members during labor is not a common practice among Hispanic clients, as they tend to value family support and involvement during childbirtH. The nurse should respect the client's preferences and allow the family members to be present if the client wishes.
Choice B: Traditionally, Hispanic postpartum practices emphasize warmth and avoidance of cold. Cold fluids are generally discouraged, as cultural beliefs hold that they may cause imbalance or illness. Thus, requesting cold fluids immediately after delivery is unlikely.
Choice C: Practice of maternal fasting following the birth is not a common practice among Hispanic clients, as they tend to consume warm and nutritious foods and beverages to promote healing and lactation. The nurse should encourage the client to eat a balanced diet and provide culturally appropriate foods if possiblE.
Choice D: Delaying breastfeeding for several days is a recognized cultural practice among some Hispanic families. Colostrum may be viewed as “dirty” or insufficient, and mothers may wait until mature milk comes in before initiating breastfeeding. Nurses should anticipate this belief and provide culturally sensitive education about the benefits of early breastfeeding while respecting the client’s values.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: Explaining to the client what is happening over the next few minutes in detail and asking for teach back from the spouse is not the first action, as it may delay the urgent intervention and increase the anxiety of the client and the spousE. The nurse should provide brief and clear information and reassurance after taking the first action.
Choice B: Placing the client in a knee-chest or Trendelenburg position and raising the presenting part off the cord with your hand is the first and most important action, as it relieves the pressure on the cord and prevents cord compression and fetal hypoxiA. The nurse should maintain this position until the delivery.
Choice C: Covering the cord with a sterile, moist saline dressing is a secondary action, as it prevents the cord from drying and reduces the risk of infection. The nurse should perform this action after taking the first action.
Choice D: Preparing the client for an emergency cesarean birth is a tertiary action, as it is the definitive treatment for cord prolapse and ensures the safety of the mother and the fetus. The nurse should perform this action after taking the first and second actions.
Correct Answer is ["B","C","D"]
Explanation
Choice A: Massaging a firm fundus is not necessary, as it indicates that the uterus is contracting well and preventing excessive bleedinG. Massaging a firm fundus may cause discomfort and increase the risk of infection.
Choice B: Determining whether the fundus is midline is an important action, as it indicates that the uterus is in the correct position and not displaced by a full bladder or hematomA. A deviated fundus may cause uterine atony and hemorrhagE.
Choice C: Observing the lochia during palpation of fundus is an important action, as it indicates the amount and type of vaginal discharge after delivery. The nurse should assess the color, odor, consistency, and quantity of lochia and report any abnormal findings.
Choice D: Documenting fundal height is an important action, as it indicates the involution of the uterus after delivery. The nurse should measure the distance from the symphysis pubis to the top of the fundus in centimeters and compare it with the expected findings.
Choice E: Administering terbutaline if the fundus is boggy is not an appropriate action, as terbutaline is a tocolytic agent that relaxes the uterine muscles and may worsen the bleedinG. The nurse should massage a boggy fundus until it becomes firm and notify the provider.
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