A 25-year-old gravida 1 para 1 who had an emergency cesarean birth 3 days ago is scheduled for discharge. As the nurse prepares her for discharge, she begins to cry. What action should the nurse take first?
Point out how lucky she is to have a healthy baby
Assess her for pain
Explain that she is experiencing postpartum blues
Allow her time to express her feelings
The Correct Answer is D
Choice A: This is incorrect because pointing out how lucky she is to have a healthy baby may invalidate her feelings and make her feel guilty or ashamed. The nurse should acknowledge and respect the client's emotions and avoid making judgments or comparisons.
Choice B: This is incorrect because assessing her for pain is not the first action that the nurse should take. Although pain may be a factor that contributes to the client's emotional state, it is not the primary cause of her crying. The nurse should first establish rapport and trust with the client and then assess her physical and psychological needs.
Choice C: This is incorrect because explaining that she is experiencing postpartum blues may be premature and inaccurate. Postpartum blues are mild and transient mood changes that occur in up to 80% of women within the first few days after childbirth. They are characterized by tearfulness, irritability, anxiety, and mood swings. However, the nurse should not assume that the client has postpartum blues without performing a thorough assessment and ruling out other possible causes of her crying, such as postpartum depression, anxiety, or trauma.
Choice D: This is the correct answer because allowing her time to express her feelings is the most appropriate and empathetic action that the nurse should take first. The nurse should listen actively and attentively to the client and provide emotional support and reassurance. The nurse should also use open-ended questions and reflective statements to facilitate communication and explore the client's concerns and coping strategies.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: This is incorrect because lanugo is a fine, downy hair that covers the fetus in utero. It usually disappears by the 36th week of gestation, but it may persist in some preterm infants. Lanugo helps to retain body heat and protect the skin from amniotic fluid. Lanugo is not a sign of postmaturity, but of prematurity or intrauterine growth restriction.
Choice B: This is incorrect because a short, chubby appearance is typical of a term infant, who is born between 37 and 42 weeks of gestation. A term infant has a well-developed subcutaneous fat layer that gives them a rounded shape and smooth skin. A term infant also has a head circumference that is proportional to their body length and weight. A short, chubby appearance is not a sign of postmaturity, but of normal development.
Choice C: This is incorrect because vernix caseosa is a white, cheesy substance that covers the fetus in utero. It usually decreases by the 40th week of gestation, but it may remain in some term infants, especially in the skin folds. Vernix caseosa helps to moisturize and protect the skin from amniotic fluid and infection. Vernix caseosa is not a sign of postmaturity, but of term or near-term gestation.
Choice D: This is the correct answer because cracked, peeling skin is a common sign of postmaturity, which occurs when the infant is born after 42 weeks of gestation. A postmature infant has a loss of subcutaneous fat and water that results in dry, wrinkled, and desquamated skin. A postmature infant also has a large head circumference that is disproportionate to their body length and weight. Cracked, peeling skin indicates prolonged exposure to amniotic fluid and placental insufficiency.
Correct Answer is B
Explanation
Choice A) Increased urinary output: This is not a sign of sepsis in newborns. In fact, sepsis can cause reduced urinary output due to poor blood flow to the kidneys and dehydration.
Choice B) Hypothermia: This is a sign of sepsis in newborns. Sepsis can cause changes in temperature, often fever, but sometimes low temperature. Hypothermia can indicate a severe infection that affects the body's ability to regulate its temperature.
Choice C) Wakefulness: This is not a sign of sepsis in newborns. Sepsis can cause reduced activity and lethargy due to inflammation and organ dysfunction.
Choice D) Interest in feeding: This is not a sign of sepsis in newborns. Sepsis can cause reduced sucking and difficulty feeding due to poor appetite, nausea, vomiting, and abdominal distension.
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