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: Take naproxen for generalized discomfort
Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) that can help with generalized discomfort. However, NSAIDs can cause fluid retention and worsen heart failure symptoms. They can also increase the risk of kidney damage and gastrointestinal bleeding, especially in individuals with heart failure. Therefore, it is generally advised to avoid NSAIDs and use alternative pain relief methods, such as acetaminophen, under the guidance of a healthcare provider.
Choice B: Notify the provider of a weight gain of 0.5 kg (1 lb) in a week
Monitoring weight is crucial for individuals with heart failure, as sudden weight gain can indicate fluid retention and worsening heart failure. A weight gain of 0.5 kg (1 lb) in a week is significant and should be reported to the healthcare provider immediately. This allows for timely intervention to adjust medications or other treatments to prevent further complications. Regular weight monitoring helps in early detection of fluid buildup and effective management of heart failure.
Choice C: Take diuretics early in the morning and before bedtime
Diuretics are commonly prescribed to help reduce fluid buildup in individuals with heart failure. However, taking diuretics before bedtime can lead to frequent nighttime urination, disrupting sleep. It is generally recommended to take diuretics early in the morning to minimize this issue. If a second dose is needed, it should be taken in the early afternoon to avoid nighttime disturbances.
Choice D: Exercise at least three times per week
Regular exercise is beneficial for individuals with heart failure as it helps improve cardiovascular health, increase stamina, and reduce symptoms. However, the exercise regimen should be tailored to the individual’s condition and capabilities. It is important to consult with a healthcare provider to develop a safe and effective exercise plan. Cardiac rehabilitation programs can also provide structured exercise guidance and support.
Correct Answer is C
Explanation
Choice A reason: Assist the client to sit upright in a chair for 4 hours at a time:
While it is important to mobilize patients after surgery, sitting upright for 4 hours at a time is excessive and can cause discomfort and strain on the surgical site. Early postoperative care focuses on gradual mobilization and avoiding prolonged positions that could stress the spine.
Choice B reason: Expect clear drainage on the spinal dressing:
Clear drainage on the spinal dressing is not typical and could indicate a cerebrospinal fluid (CSF) leak, which is a serious complication. Any unexpected drainage should be reported to the healthcare provider immediately.
Choice C reason: Log roll the client every 2 hours:
Log rolling is a technique used to turn patients while keeping the spine in alignment. This method is crucial for patients who have undergone spinal surgery to prevent twisting or bending of the spine, which could disrupt the surgical site and impede healing. Regular repositioning also helps prevent pressure ulcers.
Choice D reason: Perform neurological checks every 8 hours:
Neurological checks are essential after spinal surgery to monitor for any changes in sensation, movement, or function. However, these checks are typically performed more frequently than every 8 hours, especially in the immediate postoperative period.
