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 ["A","B","D","E"]
Explanation
Choice A rationale
Uterine atony is the leading cause of postpartum hemorrhage, resulting in significant blood loss and hypovolemia. Increasing intravenous fluid replacement with crystalloid solutions (e.g., normal saline or lactated Ringer's) is critical to restoring circulating blood volume, maintaining hemodynamic stability, and preventing hypovolemic shock.
Choice B rationale
A full bladder can displace the uterus and impede its ability to contract effectively, contributing to or worsening uterine atony. Inserting an indwelling urinary catheter (Foley catheter) ensures continuous bladder drainage and decompression, allowing the uterus to move into its proper place and contract more effectively.
Choice C rationale
Monitoring deep tendon reflexes (DTRs) is primarily an assessment for magnesium sulfate toxicity in clients being treated for preeclampsia or eclampsia. While relevant in those specific conditions, it is not a direct intervention for managing the immediate effects or cause of postpartum hemorrhage due to uterine atony. Normal DTR response is 2+.
Choice D rationale
Quantifying blood loss is essential for determining the severity of the hemorrhage and the efficacy of interventions. Initiating a peri-pad count and accurately weighing the pads provides a reliable, though often underestimated, measure of blood loss, guiding the need for additional fluids, blood products, or uterotonic medications.
Choice E rationale
Uterine atony is a failure of the uterine muscle to contract and compress the blood vessels at the placental site. Performing a fundal massage stimulates the myometrium to contract, thereby physically compressing the vessels and activating the natural physiological mechanisms to stop the bleeding; this is a primary, initial intervention.
Choice F rationale
Tocolytic therapy, such as terbutaline or nifedipine, works by relaxing the uterine muscle, which is used to stop preterm labor. In the context of uterine atony, the goal is to contract the uterus, so administering tocolytic therapy would be contraindicated as it would worsen the atony and accelerate blood loss.
Correct Answer is ["B","C","E","F"]
Explanation
Choice A rationale
Increased pain with urination, known as dysuria, is a primary symptom often associated with a urinary tract infection (UTI), not specifically polyhydramnios. While an enlarged uterus could theoretically cause compression and urinary symptoms, dysuria is a localized inflammatory response from the lower urinary tract, caused by microbial pathogens ascending the urethra, leading to mucosal irritation and pain during micturition.
Choice B rationale
A tense (firm) uterus is a key physical sign of polyhydramnios, reflecting the excessive accumulation of amniotic fluid. This fluid volume stretches the myometrium, leading to palpable firmness or rigidity upon abdominal assessment. Normal amniotic fluid volume in the third trimester is approximately 800-1000 mL, while polyhydramnios involves a volume typically exceeding 2000 mL or an Amniotic Fluid Index (AFI) greater than 24-25 cm.
Choice C rationale
Difficulty auscultating fetal heart sounds occurs because the excessive amniotic fluid acts as a buffer or sound barrier, significantly dampening the transmission of the fetal heart sounds to the mother's abdomen. The fluid-filled space between the fetal chest wall and the uterine wall scatters the sound waves, making the detection of the fetal heart rate via external Doppler or stethoscope challenging.
Choice D rationale
Sudden weight loss is not characteristic of polyhydramnios; in fact, the opposite is expected. The massive volume increase from the excess amniotic fluid, coupled with the enlarged fetus and placenta, typically results in a rapid or excessive maternal weight gain, far exceeding the normal gestational weight gain rate for the specific trimester.
Choice E rationale
Maternal shortness of breath (dyspnea) is a common symptom of severe polyhydramnios. The dramatically enlarged uterus pushes the diaphragm cephalad (upward), mechanically restricting the downward excursion of the diaphragm during inspiration, thereby reducing the functional lung capacity and making breathing more difficult, especially when the client is supine.
Choice F rationale
A uterus larger than expected for gestational week (LGA), also termed fundal height greater than dates, is a primary clinical finding of polyhydramnios. The excessive fluid distends the uterus significantly more than a normal pregnancy would, causing the measured fundal height to exceed the expected measurement (typically ≥ 3 cm difference) based on the last menstrual period and standard growth charts.
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