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 C
Explanation
Choice A rationale: Kernicterus is a severe form of jaundice that can result from untreated hyperbilirubinemia in a newborn. The indirect Coombs test does not assess the risk of kernicterus specifically.
Choice B rationale: The indirect Coombs test detects Rh-negative antibodies in the mother's blood, not Rh-positive antibodies.
Choice C rationale: The indirect Coombs test, also known as the indirect antiglobulin test (IAT), is performed on a pregnant woman to detect the presence of Rh-negative antibodies in her blood. If the mother is Rh-negative and has been sensitized to Rh-positive blood, these antibodies can cross the placenta and attack the red blood cells of an Rh-positive fetus, potentially causing hemolytic disease of the newborn (HDN) or erythroblastosis fetalis.
Choice D rationale: The direct Coombs test (direct antiglobulin test) is used to detect the presence of maternal antibodies that have already been attached to the newborn's red blood cells. The indirect Coombs test is used to identify the presence of these antibodies in the mother's blood before they have attached to the newborn's red blood cells.
Correct Answer is D
Explanation
Choice A rationale: This response is not supportive and may cause the client to feel pressured or inadequate. It is essential to be empathetic and understanding of the client's feelings and needs.
Choice B rationale: The nurse should encourage the client to begin breastfeeding and offer support if needed. This response does not promote the client's active involvement in caring for her newborn.
Choice C rationale: While breastfeeding is a natural process, it can be challenging for some women, especially in the early days. This response may minimize the client's concerns and emotions.
Choice D rationale: The nurse should be supportive and reassuring to the postpartum client. The client may be feeling overwhelmed or uncertain about breastfeeding, so offering assistance and staying with the client to help with the first feeding is an appropriate and compassionate response.
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