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:
Inserting a nasogastric tube is not the first-line intervention for postoperative nausea and vomiting (PONV). This invasive procedure is typically reserved for severe cases where other interventions have failed.
Choice B reason:
Administering an antiemetic is the appropriate action. Antiemetics help control nausea and vomiting, which are common side effects of opioids like morphine. This intervention can provide immediate relief and improve the client’s comfort.
Choice C reason:
Auscultating bowel sounds is important for assessing gastrointestinal function, but it does not directly address the immediate symptom of nausea and vomiting. This assessment can be part of the overall evaluation but is not the primary intervention.
Choice D reason:
Encouraging the client to ambulate is beneficial for overall recovery and can help reduce the risk of complications such as deep vein thrombosis. However, it does not directly address the immediate issue of nausea and vomiting.
Correct Answer is C
Explanation
Choice A reason: Pruritus:
Pruritus, or itching, can be uncomfortable and may indicate underlying conditions such as dry skin, allergies, or liver disease. However, it is not typically an immediate threat to health and can often be managed with topical treatments or antihistamines.
Choice B reason: Swollen gums:
Swollen gums can be a sign of gingivitis or other dental issues. While important to address, it is not usually an urgent condition unless it is causing severe pain or infection. Dental problems can lead to complications if untreated, but they are generally not life-threatening.
Choice C reason: Dysphagia:
Dysphagia, or difficulty swallowing, is a serious condition that can lead to aspiration, malnutrition, and dehydration. It can be caused by neurological disorders, structural abnormalities, or other medical conditions. Because it can directly impact the client’s ability to eat and drink safely, it is a priority for immediate assessment and intervention.
Choice D reason: Urinary hesitancy:
Urinary hesitancy, or difficulty starting urination, can be a symptom of benign prostatic hyperplasia (BPH) or other urinary tract issues. While it can cause discomfort and lead to urinary retention, it is generally not as immediately life-threatening as dysphagia.