A nurse is assisting with the admission of a client who is Hispanic to the labor and delivery unit. Which of the following practices should the nurse anticipate while caring for this client? (Select onE.:
Absence of family members during labor
Request to drink cold fluids immediately after delivery
Practice of maternal fasting following the birth
Desire to delay breastfeeding for several days
The Correct Answer is D
Choice A: Absence of family members during labor is not a common practice among Hispanic clients, as they tend to value family support and involvement during childbirtH. The nurse should respect the client's preferences and allow the family members to be present if the client wishes.
Choice B: Traditionally, Hispanic postpartum practices emphasize warmth and avoidance of cold. Cold fluids are generally discouraged, as cultural beliefs hold that they may cause imbalance or illness. Thus, requesting cold fluids immediately after delivery is unlikely.
Choice C: Practice of maternal fasting following the birth is not a common practice among Hispanic clients, as they tend to consume warm and nutritious foods and beverages to promote healing and lactation. The nurse should encourage the client to eat a balanced diet and provide culturally appropriate foods if possiblE.
Choice D: Delaying breastfeeding for several days is a recognized cultural practice among some Hispanic families. Colostrum may be viewed as “dirty” or insufficient, and mothers may wait until mature milk comes in before initiating breastfeeding. Nurses should anticipate this belief and provide culturally sensitive education about the benefits of early breastfeeding while respecting the client’s values.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: Administering saline drops into the newborn's nares is not the first action, as it can cause aspiration and irritation of the nasal mucosA. The nurse should clear the airway of the newborn before administering any medication or fluiD.
Choice B: Suctioning the newborn's mouth first and then the nose with a bulb syringe is the first and most important action, as it can remove the excess mucus and prevent obstruction and aspiration of the airway. The nurse should squeeze the bulb syringe before inserting it into the mouth or nose and release it gently to create suction. The nurse should suction the mouth before the nose to avoid pushing the mucus back into the throat.
Choice C: Placing the newborn in Trendelenburg position is not an appropriate action, as it can cause the mucus to flow back into the throat and lungs and increase the risk of aspiration and infection. The nurse should keep the newborn's head slightly lower than the chest to facilitate the drainage of the mucus.
Choice D: Performing deep suctioning of the newborn's trachea with an endotracheal tube is not an appropriate action, as it can cause trauma and inflammation of the trachea and vocal cords and increase the risk of bleeding and infection. The nurse should only perform this action if the newborn has signs of respiratory distress or meconium aspiration and under the supervision of a provider.
Correct Answer is ["A","C","D"]
Explanation
Choice A: Amniotic fluid in the vaginal vault indicates that the client's membranes have ruptured, which is a sign of labor. The fluid should be clear and odorless. The nurse should assess the fetal heart rate and monitor for signs of infection or cord prolapsE.
Choice B: Pain just above the navel is not a sign of labor. It may indicate other conditions such as gastritis, gallstones, or pancreatitis. The pain of labor is usually felt in the lower back and abdomen and radiates to the thighs.
Choice C: Cervical dilation is a sign of labor. It indicates that the cervix is opening and thinning to allow the passage of the fetus. The nurse should measure the cervical dilation in centimeters and document the progress of labor.
Choice D: Contractions every 3 to 4 minutes are a sign of labor. They indicate that the uterus is contracting and pushing the fetus downwarD. The nurse should assess the frequency, duration, and intensity of the contractions and monitor the fetal responsE.
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