A client who is breastfeeding her newborn tells the nurse, "I notice that when I feed him, I feel fairly strong contraction-like pain. Labor is over. Why am I having contractions now?" Which response by the nurse would be most appropriate?
Select one:
"Your body is responding to the events of labor, just like after a tough workout."
"This could be a sign that your body is trying to get rid of retained placental fragments."
"Let me check your vaginal discharge just to make sure everything is fine."
"The baby's sucking releases oxytocin which causes your uterus to contract."
The Correct Answer is D
Choice A Reason: "Your body is responding to the events of labor, just like after a tough workout." This is an inaccurate statement that does not explain the cause of the contractions or reassure the client.
Choice B Reason: "This could be a sign that your body is trying to get rid of retained placental fragments." This is an alarming statement that may scare the client and imply that something is wrong. Retained placental fragments are rare and usually cause heavy bleeding, fever, and infection.
Choice C Reason: "Let me check your vaginal discharge just to make sure everything is fine." This is an unnecessary statement that does not answer the client's question or provide any information.
Choice D Reason: "The baby's sucking releases oxytocin which causes your uterus to contract." This is a correct statement that explains the physiological mechanism of the contractions and reassures the client that they are normal and beneficial.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason: A fetal heart rate baseline of 140 with one acceleration to 155 for 15 seconds within 30 minutes. This is an incorrect answer that indicates a non-reactive NST, which is a test that does not meet the criteria for a reactive NST. A non-reactive NST may suggest fetal hypoxia, distress, or sleep, but it does not necessarily indicate a problem. A non-reactive NST may require further testing or stimulation to elicit a reactive result.
Choice B Reason A fetal heart rate baseline of 140 with two accelerations to 160 for 15 seconds within 20 minutes. This is because this strip meets the criteria for a reactive NST, which is a non-invasive test that evaluates fetal well- being and oxygenation by measuring the fetal heart rate response to fetal movements. A reactive NST is defined as having at least two accelerations of the fetal heart rate that are at least 15 beats per minute above the baseline and last for at least 15 seconds within a 20-minute period.
Choice C Reason: A fetal heart rate baseline of 130 with two accelerations to 135 for 15 seconds within 20 minutes. This is an incorrect answer that indicates a non-reactive NST, which is a test that does not meet the criteria for a reactive NST. The accelerations in this strip are not sufficient in amplitude, as they are only 5 beats per minute above the baseline, instead of at least 15 beats per minute.
Choice D Reason: A fetal heart rate baseline of 150 with two accelerations to 160 for 10 seconds within 20 minutes. This is an incorrect answer that indicates a non-reactive NST, which is a test that does not meet the criteria for a reactive NST. The accelerations in this strip are not sufficient in duration, as they last only for 10 seconds, instead of at least 15 seconds.
Correct Answer is D
Explanation
Choice A Reason: About 1 of every 5 women will experience abuse in her lifetime is a statistic that shows the prevalence of domestic violence, but it does not address the question of what the nurse should emphasize to the group of women.
Choice B Reason: When women go back to the situation after the abuser has calmed down, things will be beter is a false statement that reflects the cycle of abuse, where the abuser may apologize and promise to change after a violent episode, but then repeat the same behavior later. This does not help the women understand their situation or seek help.
Choice C Reason: The victimized woman can easily leave the situation is a false statement that ignores the many barriers and challenges that women face when trying to escape from domestic violence, such as fear, isolation, financial dependence, lack of support, legal issues, and threats from the abuser. This does not empower the women or provide them with realistic options.
Choice D Reason: The violence will not stop or decrease if the woman becomes pregnant is a true statement that highlights the danger of staying in an abusive relationship during pregnancy. Domestic violence can increase the risk of miscarriage, preterm birth, low birth weight, placental abruption, fetal injury, and maternal death. This may motivate the women to seek safety and protection for themselves and their unborn children.
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