A nurse is caring for a client who is 1 day postpartum. The client tells the nurse, "The baby has been breathing funny, fast and slow, off and on." Which of the following responses should the nurse make?
"There's absolutely nothing for you to worry about. Newborns often breathe like this."
"I'll sit here while you feed him and we'll check out his breathing."
"You are going to be a very good, responsible mother to this baby."
"All new mothers feel a bit anxious about things like this."
The Correct Answer is B
Choice A rationale: While it's true that newborns can have irregular breathing patterns, this response may come across as dismissive and not addressing the client's concerns.
Choice B rationale: The nurse should respond by actively listening to the client's concerns and offering to assess the newborn's breathing while they are feeding. Newborns can have irregular breathing patterns, including periods of rapid breathing (tachypnea) and pauses in breathing (periodic breathing). These patterns are generally normal and related to the baby's immature respiratory system adjusting to life outside the womb.
Choice C rationale: This response does not address the client's concern about the baby's breathing and instead focuses on the client's potential as a mother.
Choice D rationale: This response may minimize the client's concerns and does not address the baby's breathing issue. It's essential to acknowledge and assess the newborn's breathing pattern to ensure it is within the normal range.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: The correct term to document this finding is "Quickening." Quickening refers to the first perception of fetal movement by the pregnant woman, usually described as light fluttering or sensation of movement in the abdomen. It is an exciting milestone for pregnant women and often occurs around 18 to 20 weeks of gestation. It is a significant moment as it indicates the woman can feel the baby's movements, signifying the fetus's increasing activity and growth.
Choice B rationale: Ballottement is a physical examination technique used to assess the fetus's position and movement within the amniotic fluid during pregnancy. It involves a gentle tap on the mother's abdomen to feel the fetus bounce or float in the amniotic fluid.
Choice C rationale: Chloasma, also known as the "mask of pregnancy," refers to dark patches of skin that may appear on the face during pregnancy due to hormonal changes. It is not related to the sensation of fetal movement.
Choice D rationale: Lightening, also known as "engagement," is the process in late pregnancy when the baby's head descends into the pelvis, preparing for childbirth. It often occurs a few weeks before labor begins and can result in the mother feeling less pressure on her diaphragm, which may make breathing easier. It is not related to the perception of fetal movement described by the client.
Correct Answer is A
Explanation
Choice A rationale: The Moro reflex, also known as the startle reflex, is elicited by making a loud noise or performing a sharp hand clap near the newborn. In response to the stimulus, the newborn will throw their arms and legs outward and then bring them back toward the center of the body.
Choice B rationale: Placing a finger at the base of the newborn's toes is not related to eliciting the Moro reflex. This action may elicit the Babinski reflex, which causes the toes to fan out and the big toe to dorsiflex.
Choice C rationale: This action may elicit the stepping reflex, where the newborn will make stepping movements when the soles of their feet touch a flat surface. It is not related to eliciting the Moro reflex.
Choice D rationale: Turning the newborn's head quickly to one side is not related to eliciting the Moro reflex. This action may elicit the asymmetric tonic neck reflex (ATNR), where the newborn will extend the arm and leg on the side their head is turned to and flex the opposite arm and leg.
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