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: Blurred vision:
While blurred vision can occur in some cases of meningitis, it is not one of the most common or definitive symptoms. Meningitis primarily affects the meninges, leading to symptoms like headache, fever, and neck stiffness. Blurred vision might be a secondary symptom due to increased intracranial pressure, but it is not as typical as other symptoms.
Choice B reason: Severe headache:
A severe headache is a hallmark symptom of meningitis. This headache is often described as intense and different from typical headaches. It is caused by the inflammation of the meninges, which are the protective membranes covering the brain and spinal cord. The headache is usually accompanied by other symptoms such as fever, neck stiffness, and sensitivity to light.
Choice C reason: Oriented to person, place, and year:
Being oriented to person, place, and year indicates normal cognitive function. However, meningitis can cause confusion, altered mental status, and even loss of consciousness in severe cases. Therefore, this finding would not be expected in a client with meningitis.
Choice D reason: Bradycardia:
Bradycardia, or a slow heart rate, is not typically associated with meningitis. Meningitis symptoms are more related to the central nervous system and include fever, headache, neck stiffness, and altered mental status. Bradycardia might occur in other conditions but is not a common finding in meningitis.
Correct Answer is C
Explanation
Choice A reason:
Promoting oral hygiene is important for preventing infection and maintaining overall health, especially after surgery involving the mouth. However, it is not the immediate priority in the postoperative period.
Choice B reason:
Ensuring adequate nutrition is crucial for healing and recovery, but it is not the most urgent concern immediately after surgery. Nutritional needs can be addressed once the client is stable and the risk of complications has been minimized.
Choice C reason:
Preventing aspiration is the priority action. After surgery for a fractured mandible with intermaxillary fixation, the client is at high risk for aspiration due to the inability to open the mouth and clear secretions effectively. Aspiration can lead to serious complications such as pneumonia, making it the most critical concern.
Choice D reason:
Relieving the client’s pain is important for comfort and recovery, but it is not the highest priority immediately after surgery. Pain management should be addressed once the client’s airway and breathing are secure.
