A nurse is caring for a client who experienced a cesarean birth due to dysfunctional labor. The client states that she is disappointed that she did not have natural childbirth. Which of the following responses should the nurse make?
"Maybe next time you can have a vaginal delivery."
"It sounds like you are feeling sad that things didn't go as planned."
"You can resume sexual relations sooner than if you had delivered vaginally."
"At least you know you have a healthy baby."
The Correct Answer is B
A) "Maybe next time you can have a vaginal delivery.": This response may not be appropriate as it assumes a future pregnancy and vaginal delivery is guaranteed. It may not address the client's current feelings of disappointment adequately.
B) "It sounds like you are feeling sad that things didn't go as planned.": This is the correct answer as it shows empathy and validates the client's feelings of disappointment. It acknowledges the client's emotions and provides support during this sensitive time.
C) "You can resume sexual relations sooner than if you had delivered vaginally.": While this statement may be true, it is not directly related to the client's expressed feelings of disappointment.
D) "At least you know you have a healthy baby.": This response dismisses the client's feelings and may not be wellreceived, as the client is expressing a desire for emotional support rather
than a reassurance about the baby's health.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: After an amniotomy (artificial rupture of membranes), the priority action by the nurse is to assess the fetal heart rate. Amniotomy can lead to changes in fetal heart rate patterns, and the nurse needs to ensure that the baby's wellbeing is not compromised after the procedure.
Choice B: Providing clean, dry underpads is important for maintaining hygiene and cleanliness after the procedure but is not the priority action. The fetal heart rate assessment takes precedence.
Choice C: Assessing the odor of the amniotic fluid is essential to identify any signs of infection, but it is not the priority action immediately following the amniotomy. Fetal wellbeing is the priority.
Choice D: Monitoring the client's temperature is important for identifying any signs of infection, but it is not the priority action. Assessing the fetal heart rate is more critical at this time.
Correct Answer is A
Explanation
A) Quickening: Quickening is the term used to describe the first perception of fetal movements by the pregnant woman. It typically occurs between 16 to 20 weeks of gestation, which aligns with the client's statement about feeling fluttering movements at 18 weeks.
B) Ballottement: Ballottement is a physical examination technique performed by a healthcare provider to assess the fetus's position in the uterus. It is not related to the client's perception of fetal movement.
C) Chloasma: Chloasma refers to hyperpigmented skin areas that can appear during pregnancy due to hormonal changes. It is not related to fetal movement.
D) Lightening: Lightening refers to the descent of the fetal head into the maternal pelvis, which typically occurs in the third trimester. It is not related to the feeling of fetal movements by the mother.
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