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 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."

"You can resume sexual relations sooner than if you had delivered vaginally."

"At least you know you have a healthy baby."

Answer and Explanation

The Correct Answer is B

A)   "Maybe next time you can have a vaginal delivery.": This response may not be appropriate as it assumes a future pregnancy and vaginal delivery is guaranteed. It may not address the client's current feelings of disappointment adequately.
B)   "It sounds like you are feeling sad that things didn't go as planned.": This is the correct answer as it shows empathy and validates the client's feelings of disappointment. It acknowledges the client's emotions and provides support during this sensitive time.

C)   "You can resume sexual relations sooner than if you had delivered vaginally.": While this statement may be true, it is not directly related to the client's expressed feelings of disappointment.
D)   "At least you know you have a healthy baby.": This response dismisses the client's feelings and may not be wellreceived, as the client is expressing a desire for emotional support rather
than a reassurance about the baby's health.

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Correct Answer is D

Explanation

A) A reactive test: A reactive NST requires the presence of specific criteria, including at least two fetal heart rate accelerations of at least 15 beats per minute (bpm) lasting for at least 15
seconds in a 20minute period, along with a baseline heart rate within the normal range (110160 bpm) and moderate variability.
B) A negative test: "Negative" is not a term used to describe NST results.

C) A positive test: "Positive" is not a term used to describe NST results.

D) A nonreactive test: This is the correct interpretation. In a nonreactive NST, the fetal heart rate did not demonstrate the required accelerations within the 30minute observation period. The absence of accelerations can indicate potential fetal compromise, and further evaluation, such as a contraction stress test or biophysical profile, may be necessary to assess the fetus's wellbeing.

A. Assist the client to an upright position. B. Prepare for a cesarean birth. C. Assist the client to turn onto her side. D. Prepare for an immediate vaginal delivery.

Correct Answer is C

Explanation

Choice A: While an upright position is generally beneficial during labor to improve uterine contractions and fetal positioning, it is not the priority in this situation of hypotension.
Choice B: Preparing for a cesarean birth is not indicated solely based on the blood pressure reading. Cesarean birth should be considered based on the overall assessment and clinical condition of the client and baby.
Choice C: The client's blood pressure reading of 82/52 mm Hg indicates hypotension. In this situation, the nurse should assist the client in turning onto her side to relieve pressure on the vena cava and improve blood flow to the placenta and the baby. Lying supine can compress the vena cava, leading to decreased venous return and reduced cardiac output, which may negatively affect fetal oxygenation and maternal wellbeing.
Choice D: Preparing for an immediate vaginal delivery is not the priority at this moment. The nurse should first address the hypotension and improve maternal blood flow before proceeding with delivery.

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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 natural childbirth. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

Correct Answer is C

Explanation

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