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: Auscultating fetal heart tones in the right upper quadrant is not appropriate based on the information provided by Leopold maneuvers, which indicates the fetal back is on the right side of the mother's abdomen, and the fetal head is in the fundal portion of the uterus.
Choice B rationale: During Leopold maneuvers, the nurse palpated a round, firm, movable part in the fundal portion of the uterus. This finding corresponds to the fetal head, which is typically located at the top of the uterus (fundus). Additionally, the nurse palpated a long, smooth surface on the mother's right side. This finding indicates the fetal back, which typically lies along the right side of the mother's abdomen, suggesting that the fetus's back is positioned anteriorly (toward the mother's front). The location of the fetal heart is typically best heard over the back of the fetus. Therefore, the nurse should auscultate the fetal heart tones in the maternal quadrant corresponding to the back of the fetus, which is the left lower quadrant.
Choice C rationale: The information from Leopold maneuvers does not indicate the fetal back is in the right lower quadrant. The nurse should not auscultate fetal heart tones in this area.
Choice D rationale: Auscultating fetal heart tones in the left upper quadrant is not appropriate based on the information provided by Leopold maneuvers, which indicates the fetal head is in the fundal portion of the uterus and the fetal back is on the right side of the mother's abdomen. The fetal heart is usually best heard over the back of the fetus, which is not in the left upper quadrant.
Correct Answer is D
Explanation
Choice A rationale:
Uterine enlargement greater than expected for gestational age is not a typical finding in a possible ectopic pregnancy. An ectopic pregnancy occurs when the fertilized egg implants outside the uterus, usually in the fallopian tube, and the uterus does not enlarge normally.
Choice B rationale:
Copious vaginal bleeding is not a typical finding in a possible ectopic pregnancy. Vaginal bleeding can occur, but it is not usually copious.
Choice C rationale:
Severe nausea and vomiting are not typically associated with a possible ectopic pregnancy. Nausea and vomiting are common symptoms in early pregnancy, but they are not specific to an ectopic pregnancy.
Choice D rationale:
Pelvic pain is a common finding in a possible ectopic pregnancy. The pain is often sharp, and unilateral, and may be located on one side of the lower abdomen or pelvis.
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