On the third postpartum day after an unexpected cesarean birth, the nurse finds the client crying. The client states, "I know my baby is fine, but I can't help crying. I wanted a natural childbirth so much.
Why did this have to happen to me?" What is the nurse's best response to the client?
A woman can feel upset after an urgent cesarean birth. Can you tell me more about your feelings.
Your feelings about this will improve after you have bonded more with your infant. I'm sorry you're upset.
You are probably suffering from postpartum depression. Do you want a referral to counseling.
Most women understand a cesarean birth is a possible outcome during birth. Did you discuss this during your prenatal visits.
The Correct Answer is A
Choice A rationale
This response validates the client's feelings ("A woman can feel upset.”.) and employs an open-ended question ("Can you tell me more.”.) to encourage further therapeutic communication. This supportive approach recognizes the client's grief over the loss of the desired birth experience and facilitates the emotional processing necessary for bonding.
Choice B rationale
Minimizing the client's current emotional state by suggesting it will improve later is non-therapeutic, as it invalidates her present feelings and can create a communication barrier. Bonding is a process, and initial upset can hinder it, but simply waiting for improvement isn't the best response.
Choice C rationale
Suggesting a diagnosis of postpartum depression (PPD) prematurely is inappropriate and anxiety-provoking. The "baby blues," which typically include emotional lability and crying on the third day, are a normal physiological and psychological adjustment due to hormonal shifts and the reality of parenthood.
Choice D rationale
Asking a rhetorical, even accusatory question about prenatal discussions invalidates the client's feelings by suggesting she should have been prepared or better informed. It shifts the focus away from her current distress, failing to provide the needed emotional support and acceptance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["150"]
Explanation
Step 1 is: Calculate the infusion rate change per hour. 4 grams/hr is the initial rate, and it is titrated by 1 gram/hr every hour. The infusion started at 0800. At 0900 (1 hour later), the rate is 4 grams/hr + 1 gram/hr = 5 grams/hr. At 1000 (2 hours later), the rate is 5 grams/hr + 1 gram/hr = 6 grams/hr. At 1100 (3 hours later), the rate is 6 grams/hr + 1 gram/hr = 7 grams/hr. At 1200 (4 hours later), the rate is 7 grams/hr + 1 gram/hr = 8 grams/hr. At 1300 (5 hours later), the rate is 8 grams/hr + 1 gram/hr = 9 grams/hr.
Step 2 is: Calculate the final rate in mL/hr using the concentration and the final grams/hr rate. The concentration is 60 grams÷ 1000 mL. The rate at 1300 is 9 grams/hr. 9 grams/hr× (1000 mL÷ 60 grams). 9000 mL/hr÷ 60. 150 mL/hr. The rate of infusion at 1300 is 150.
Correct Answer is D
Explanation
Choice A rationale
Amniotomy is the artificial rupture of membranes, a procedure to induce or augment labor. With the cervix being only 2 cm dilated and 70% effaced, the cervix is considered unfavorable, and performing an amniotomy with an unfavorable cervix may increase the risk of infection and has a higher chance of a failed induction, hence it is not the best choice.
Choice B rationale
The second stage of labor begins with complete cervical dilation (10 cm) and ends with the birth of the baby. The patient's cervix is only 2 cm dilated, indicating she is still in the latent or active phase of the first stage of labor, making this interpretation incorrect based on the current cervical assessment.
Choice C rationale
The provided assessment data focuses on cervical status and gestational age. The fetal status is not documented, thus fetal distress cannot be determined or inferred from a 2 cm dilated and 70% effaced cervix at 42 weeks' gestation. Fetal distress is identified via nonreassuring FHR patterns.
Choice D rationale
The client is a primigravida at 42 weeks' gestation with an unfavorable cervix (only 2 cm dilated and 70% effaced). The combination of post-term pregnancy and failed cervical ripening or inability to achieve adequate labor progression often leads to failed induction, for which a Cesarean birth is often the eventual anticipated outcome.
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