A nurse is caring for a client who is 24 hr postpartum and is breastfeeding her newborn. The client asks the nurse to warm up seaweed soup that the client's partner brought for her. Which of the following responses should the nurse make?
"Why are you eating seaweed soup?"
"The hospital food is more nutritious for you."
"Does the doctor know that you are eating that?"
"Of course, I will heat that up for you."
The Correct Answer is D
A. "Why are you eating seaweed soup?" This response is judgmental and dismissive of the client’s cultural practices. It can make the client feel misunderstood or disrespected.
B. "The hospital food is more nutritious for you." This statement is inaccurate and culturally insensitive, assuming that hospital food is superior without recognizing the nutritional and emotional value of traditional foods.
C. "Does the doctor know that you are eating that?" This implies unnecessary medical concern and may make the client feel like her personal choices require approval, which can be disempowering and disrespectful.
D. "Of course, I will heat that up for you." This response is supportive and culturally competent, respecting the client's traditions and preferences while promoting comfort and emotional well-being during the postpartum period.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Revise the current policy for catheter care. Policy changes should be based on evidence and root cause analysis. Revising the policy prematurely without identifying contributing factors may not address the actual causes of infection.
B. Schedule nursing staff training for infection control procedures. Education and training are important but should be guided by identified gaps. Implementing training without understanding the root cause may result in ineffective interventions.
C. Meet with providers to discuss measures to decrease the infections. While interdisciplinary collaboration is valuable, it should occur after gathering and analyzing relevant data. This ensures targeted, evidence-based recommendations.
D. Identify possible precipitating factors related to the infections. The first step in quality improvement is to investigate and assess contributing factors. This helps guide the most appropriate and effective interventions to reduce infection rates.
Correct Answer is ["A","B","C","D","E","F","G","H"]
Explanation
- Client reports feeling unwell: This is clinically significant when combined with fever, foul-smelling lochia, and elevated WBCs; it could indicate systemic infection such as endometritis.
- Fundus boggy but firms with massage: Indicates uterine atony, a risk factor for postpartum hemorrhage. Even if it responds to massage, repeated bogginess suggests the need for uterotonic medications and close monitoring.
- Foul-smelling, dark brown lochia: These findings are highly suggestive of uterine infection (endometritis), especially when paired with uterine tenderness, fever, and elevated WBCs.
- WBC count 33,000/mm³: Severely elevated — well above normal postpartum leukocytosis (typically up to 20,000/mm³). A level of 33,000 strongly suggests an ongoing infectious process.
- Temperature 38.2°C (100.8°F): Slightly elevated, and while low-grade fever is common postpartum, when associated with uterine tenderness and abnormal lochia, it raises concern for infection and should be monitored and managed appropriately.
- Lung sounds diminished in the bases: Could be due to post-surgical hypoventilation, immobility, or atelectasis. Should prompt encouragement of deep breathing, incentive spirometry, and ambulation.
- No bowel movement since birth, hypoactive bowel sounds: This is a common post-cesarean finding due to anesthesia and immobility, but it still indicates delayed return of GI function and should be monitored for signs of ileus.
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