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 D
Explanation
Choice A: You Can Expect Swelling of the Ankles While Taking This Medication
Swelling of the ankles, or peripheral edema, is a known side effect of verapamil. This calcium channel blocker can cause fluid retention, leading to swelling in the lower extremities. While this is a common side effect, it is not an instruction that the nurse should include in discharge teaching. Instead, the nurse should inform the client to report any significant swelling to their healthcare provider.
Choice B: Do Not Take This Medication on an Empty Stomach
Verapamil can be taken with or without food, but taking it with food may help reduce stomach upset. Therefore, the instruction to avoid taking it on an empty stomach is not strictly necessary. The nurse should advise the client to follow their healthcare provider’s specific instructions regarding medication administration.
Choice C: Limit Your Fluid Intake to Meal Times
Limiting fluid intake to meal times is not a standard recommendation for clients taking verapamil. Adequate hydration is important for overall health, and there is no specific reason to restrict fluid intake while on this medication. The nurse should encourage the client to maintain a balanced fluid intake throughout the day.
Choice D: Increase Your Daily Intake of Dietary Fiber
Increasing daily intake of dietary fiber is a beneficial instruction for clients taking verapamil. Verapamil can cause constipation as a side effect, and a high-fiber diet can help mitigate this issue. Foods rich in fiber, such as fruits, vegetables, and whole grains, can promote regular bowel movements and improve digestive health.
Correct Answer is A
Explanation
Choice A: Administer the Medications 5 Minutes Apart
Administering the medications 5 minutes apart is crucial when using multiple eye drops. This practice ensures that each medication has enough time to be absorbed without being washed out by the subsequent drop. This is particularly important for medications like timolol and pilocarpine, which are used to manage intraocular pressure in glaucoma.
Choice B: Hold Pressure on the Conjunctival Sac for 2 Minutes Following Application of Drops
Holding pressure on the conjunctival sac (punctal occlusion) for 2 minutes after applying eye drops can help reduce systemic absorption and increase the local effect of the medication. However, this instruction is not as critical as the timing between administering different eye drops.
Choice C: It Is Not Necessary to Remove Contact Lenses Before Administering Medications
This statement is incorrect. Contact lenses should be removed before administering eye drops to prevent contamination and ensure proper absorption of the medication. The lenses can be reinserted after a sufficient amount of time has passed, usually around 15 minutes.
Choice D: Administer the Medications by Touching the Tip of the Dropper to the Sclera of the Eye
This statement is incorrect. The tip of the dropper should never touch the eye or any other surface to avoid contamination. The correct method is to hold the dropper above the eye and squeeze out the prescribed number of drops into the conjunctival sac.