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: Take the Medication with Orange Juice
Taking betamethasone with orange juice is not specifically recommended. While orange juice can help with the taste of some medications, it does not have any particular benefit for betamethasone. Additionally, citrus juices can sometimes interfere with the absorption of certain medications.
Choice B: Take the Medication Between Meals
Taking betamethasone between meals is not advised. This medication can cause stomach upset, and taking it on an empty stomach can exacerbate this issue. It is generally recommended to take corticosteroids with food to minimize gastrointestinal discomfort.
Choice C: Take the Medication on an Empty Stomach
Taking betamethasone on an empty stomach is not recommended for the same reasons as above. It can lead to stomach irritation and discomfort. Taking the medication with food or milk helps to reduce these side effects.
Choice D: Take the Medication with Milk
Taking betamethasone with milk is the correct instruction. Milk can help to buffer the stomach lining and reduce the risk of gastrointestinal irritation, which is a common side effect of corticosteroids. This practice helps to ensure that the medication is tolerated well by the client.
Correct Answer is D
Explanation
Choice A: Plan of care changes for the upcoming shift
Plan of care changes for the upcoming shift are typically included in the “Recommendation” segment of SBAR. This section focuses on what actions need to be taken next, including any changes in the care plan that the oncoming nurse should be aware of. It ensures that the incoming nurse knows what to expect and what specific tasks or interventions are required during their shift.
Choice B: Intracranial pressure readings
Intracranial pressure (ICP) readings are crucial for monitoring a client with a traumatic brain injury. However, these readings are more appropriately included in the “Assessment” segment of SBAR. The assessment section provides an analysis of the client’s current condition, including vital signs, lab results, and other critical data. This information helps the oncoming nurse understand the client’s current status and any immediate concerns.
Choice C: Glasgow results
The Glasgow Coma Scale (GCS) results are used to assess the level of consciousness in clients with brain injuries. These results should also be included in the “Assessment” segment of SBAR. The GCS score provides valuable information about the client’s neurological status and helps guide clinical decisions. Including this information in the assessment ensures that the oncoming nurse has a clear understanding of the client’s current condition.
Choice D: Code status
Code status is a critical piece of information that should be included in the “Background” segment of SBAR. The background section provides relevant clinical history and context for the current situation. Knowing the client’s code status (e.g., full code, do not resuscitate) is essential for making informed decisions about their care, especially in emergency situations. Including this information in the background ensures that the oncoming nurse is aware of the client’s preferences and legal directives.