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?
Maybe next time you can have a vaginal delivery.
It sounds like you are feeling sad that things didn’t go as planned.
At least you know you have a healthy baby.
You can resume sensations sooner than if you had delivered vaginally.
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:
Wiping from back to front is incorrect and can lead to contamination of the urine sample with bacteria from the anal area. The correct method is to wipe from front to back to reduce the risk of contamination.
Choice B reason:
Urinating a small amount in the toilet before collecting the sample is the correct procedure for obtaining a midstream urine specimen. This helps to flush out any bacteria or contaminants from the urethra, ensuring that the sample collected is as clean as possible.
Choice C reason:
Letting the urine cool to room temperature before sending it to the lab is incorrect. Urine samples should be sent to the lab as soon as possible after collection to ensure accurate results. If there is a delay, the sample should be refrigerated.
Choice D reason:
It is generally recommended to avoid collecting a urine sample during menstruation, as menstrual blood can contaminate the sample and affect the test results.
Correct Answer is B
Explanation
Choice A reason:
Intense pruritus: While itching (pruritus) can be a symptom of skin conditions, it is not a definitive sign of malignancy in nevi. Pruritus can be associated with benign conditions such as eczema or allergic reactions. However, if a mole starts to itch, it should be monitored closely, but it is not as strong an indicator of malignancy as irregular borders.
Choice B reason:
Irregular borders: This is a significant sign of potential malignancy in nevi. Melanomas often have uneven, notched, or scalloped borders, unlike benign moles, which typically have smooth, even borders. The irregularity in the border is due to the uncontrolled growth of melanocytes, which can spread unevenly.
Choice C reason:
Uniform pigmentation: Uniform pigmentation is generally a sign of a benign mole. Malignant moles often have multiple colors or an uneven distribution of color, which can include shades of brown, black, red, white, or blue. A mole with uniform color is less likely to be malignant.
Choice D reason:
Purulent drainage: While purulent drainage (pus) indicates an infection, it is not a typical sign of malignancy in nevi. Infections can occur in any skin lesion, but they do not specifically indicate cancer. Malignant moles are more likely to change in size, shape, or color rather than produce pus.