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: A Client Who Has a Small Circular Partial-Thickness Burn of the Left Calf
A small circular partial-thickness burn of the left calf is considered a minor injury in the context of a mass casualty event. This type of injury does not pose an immediate threat to life and can be managed after more critical cases are addressed. In mass casualty triage, patients with minor injuries are often categorized as “green” or “minimal” and are treated last.
Choice B: A Client Who Has Severe Respiratory Stridor and a Deviated Trachea
A client with severe respiratory stridor and a deviated trachea should be assessed first. These symptoms indicate a potential airway obstruction, which is a life-threatening condition requiring immediate intervention. In mass casualty triage, patients with compromised airways are given the highest priority and are categorized as “red” or “immediate” because their condition is critical and requires urgent medical attention.
Choice C: A Client Who Has a Splinted Open Fracture of the Left Medial Malleolus
A splinted open fracture of the left medial malleolus is a serious injury but not immediately life-threatening if properly splinted. This client would be categorized as “yellow” or “delayed” in mass casualty triage, meaning they require medical attention but can wait until more critical patients are stabilized.
Choice D: A Client Who Has a Massive Head Injury and Is Experiencing Seizures
A client with a massive head injury and experiencing seizures is in a critical condition. However, in the context of mass casualty triage, the immediate priority is to secure the airway, breathing, and circulation. While this client is in dire need of medical attention, the presence of severe respiratory stridor and a deviated trachea in another client takes precedence due to the immediate threat to life.
Correct Answer is A
Explanation
Choice A reason: Place a black tag on the client’s upper body and attempt to help the next client in need:
In mass casualty incidents, triage is used to prioritize treatment based on the severity of injuries and the likelihood of survival. A black tag indicates that the victim is deceased or has injuries that are not compatible with life and that resources should be directed to those who have a better chance of survival. Since the client remains apneic even after repositioning the airway, it indicates that they are not breathing and have a very low chance of survival.
Choice B reason: Reposition the client’s upper airway a second time before assessing his respirations:
While ensuring the airway is open is crucial, if the client remains apneic after the initial repositioning, further attempts are unlikely to be successful in a mass casualty scenario where time and resources are limited2. The priority is to move on to other victims who may have a higher chance of survival.
Choice C reason: Start CPR:
In a mass casualty situation, CPR is typically not initiated for victims who are apneic and pulseless due to the need to allocate resources to those who have a higher likelihood of survival3. The focus is on providing immediate care to those who can benefit the most from it.
Choice D reason: Place a red tag on the client’s upper body and obtain immediate help from other personnel:
A red tag is used for victims who require immediate life-saving interventions and have a high chance of survival if treated promptly4. Since the client is apneic and remains so after airway repositioning, they do not meet the criteria for a red tag.