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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 a natural childbirth. Which of the following responses should the nurse make?

A.

Maybe next time you can have a vaginal delivery.

B.

It sounds like you are feeling sad that things didn’t go as planned.

C.

At least you know you have a healthy baby.

D.

You can resume sensations sooner than if you had delivered vaginally.

Answer and Explanation

The Correct Answer is B

Choice A reason:

 

Saying “Maybe next time you can have a vaginal delivery” is not supportive and may minimize the client’s current feelings of disappointment. It is important to acknowledge and validate the client’s emotions rather than focusing on future possibilities.

 

Choice B reason:

 

This response, “It sounds like you are feeling sad that things didn’t go as planned,” is empathetic and validates the client’s feelings. It shows that the nurse is listening and understands the client’s disappointment, which is crucial for emotional support.

 

Choice C reason:

 

While it is true that having a healthy baby is important, saying “At least you know you have a healthy baby” can come across as dismissive of the client’s feelings. It is essential to address the client’s emotions directly rather than shifting the focus.

 

Choice D reason:

 

Telling the client “You can resume sensations sooner than if you had delivered vaginally” is not relevant to the client’s expressed feelings of disappointment about not having a natural childbirth. This response does not address the emotional aspect of the client’s experience.

 


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Correct Answer is B

Explanation

Choice A reason: Health care provider:

While health care providers, such as doctors, have extensive knowledge about medications and their uses, they may not always have the most up-to-date information on specific drug compatibilities. Pharmacists specialize in medications and are more likely to have immediate access to detailed compatibility data.

Choice B reason: Hospital pharmacist:

Pharmacists are the primary resource for information on drug compatibility. They have access to comprehensive databases and resources that provide detailed information on drug interactions and compatibility. Consulting the hospital pharmacist ensures that the nurse receives accurate and current information regarding the safe administration of ampicillin and gentamicin sulfate.

Choice C reason: Nurse manager:

Nurse managers oversee nursing staff and ensure that patient care standards are met. While they have a broad knowledge of clinical practices, they may not have the specific expertise or resources to provide detailed information on drug compatibility.

Choice D reason: Medication sales representative:

Medication sales representatives are knowledgeable about the products they promote, but their primary role is to market medications. They may not have the comprehensive and unbiased information needed to determine drug compatibility. It is always best to consult a pharmacist for this type of information.

Correct Answer is A

Explanation

Choice A: Flu-like symptoms and night sweats

The initial symptoms of HIV infection often resemble those of the flu. These symptoms, known as acute retroviral syndrome (ARS) or primary HIV infection, typically occur within 2 to 4 weeks after the virus enters the body. Common symptoms include fever, chills, night sweats, muscle aches, sore throat, fatigue, swollen lymph nodes, and a rash. These symptoms are the body’s natural response to the virus and indicate that the immune system is reacting to the infection. Night sweats, in particular, are a common symptom during the early stages of HIV infection.

Choice B: Fungal and bacterial infections

Fungal and bacterial infections are more commonly associated with later stages of HIV infection, particularly when the immune system has been significantly weakened. As HIV progresses and the immune system deteriorates, individuals become more susceptible to opportunistic infections, which are infections that occur more frequently and are more severe in people with weakened immune systems. These infections are not typically seen in the initial stages of HIV infection.

Choice C: Pneumocystis lung infection

Pneumocystis pneumonia (PCP) is a serious infection that occurs in people with weakened immune systems, including those with advanced HIV/AIDS. It is caused by the fungus Pneumocystis jirovecii. PCP is not an initial symptom of HIV infection but rather a complication that can arise when the immune system is severely compromised. This infection is more indicative of the later stages of HIV, particularly when the CD4 cell count drops significantly.

Choice D: Kaposi’s sarcoma

Kaposi’s sarcoma is a type of cancer that forms in the lining of blood and lymph vessels. It is caused by the human herpesvirus 8 (HHV-8) and is commonly associated with advanced HIV infection or AIDS. Kaposi’s sarcoma presents as purple, red, or brown blotches or tumors on the skin and can also affect internal organs. This condition is not an initial symptom of HIV infection but rather a manifestation of severe immune system damage in the later stages of the disease.

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