Nokea
A client, gravida 1, para 0, in active labor, is becoming increasingly anxious. Which statement by the nurse will block therapeutic communication with the client?
- A. What concerns are you having now?
- B. Tell me how you are feeling.
- C. Everything is going just fine.
- D. You seem a little nervous.
Correct Answer: C
Rationale: Correct Answer: C
Rationale:
1. Choice A and B encourage the client to express their concerns and feelings, promoting therapeutic communication.
2. Choice D acknowledges the client's emotions, showing empathy and understanding.
3. Choice C dismisses the client's anxiety, invalidating their feelings, hindering communication.
Summary:
Choices A, B, and D promote open communication and empathy, while choice C ignores the client's anxiety, making it the incorrect choice.
You may also like to solve these questions
A nurse is caring for a 3-year-old child with strabismus. Which of the following actions should the nurse advise the parents to implement to help prevent amblyopia?
- A. Wear corrective biconcave lenses.
- B. Prevent trauma to the eyes.
- C. Patch the strong eye.
- D. Instill artificial tears.
Correct Answer: C
Rationale: The correct answer is C: Patch the strong eye. Patching the strong eye helps improve vision in the weaker eye, which is essential in preventing amblyopia. By covering the strong eye, the brain is forced to rely on the weaker eye, strengthening its visual acuity. Wearing corrective biconcave lenses may help with refractive errors but does not directly address amblyopia prevention. Preventing trauma to the eyes is important for overall eye health but does not specifically target amblyopia prevention. Instilling artificial tears is used for dry eye syndrome and does not play a role in preventing amblyopia.
Which site is preferred for giving an IM injection to a newborn?
- A. Ventrogluteal
- B. Vastus lateralis
- C. Rectus femoris
- D. Dorsogluteal
Correct Answer: B
Rationale: The correct answer is B: Vastus lateralis. The vastus lateralis muscle is preferred for IM injections in newborns due to its large muscle mass, minimal risk of injury to major blood vessels and nerves, and easy accessibility. It is also recommended by healthcare guidelines for infants. Ventrogluteal and dorsogluteal sites are not recommended for newborns due to the risk of damaging nerves and blood vessels. The rectus femoris muscle is not typically used for IM injections in newborns as it is less accessible and has a higher risk of injury.
Which explanation is most appropriate when describing physiological jaundice to the parents of a newborn?
- A. The baby has a minor incompatibility of the blood.
- B. The baby is breaking down the extra red blood cells that were present at birth.
- C. The baby is getting too much breast milk, but this is not dangerous.
- D. The baby may have gotten exposed to hepatitis B during the delivery.
Correct Answer: B
Rationale: The correct answer is B: The baby is breaking down the extra red blood cells that were present at birth. Physiological jaundice in newborns occurs due to the breakdown of excess red blood cells, leading to an increase in bilirubin levels. This is a normal process as the baby's liver is still maturing.
Choice A is incorrect because minor blood incompatibility usually leads to a condition known as hemolytic disease of the newborn, not physiological jaundice. Choice C is incorrect as breast milk does not cause physiological jaundice. Choice D is incorrect because hepatitis B exposure does not directly cause physiological jaundice in newborns.
The nurse conducting a physical assessment notes that a 1-day-old newborn with dark skin has a bluish-gray discoloration over the lower back, the buttocks, and the scrotum. How should this assessment finding be documented?
- A. Extensive bruising
- B. Mongolian spots
- C. Nevus flammeus
- D. Acrocyanosis
Correct Answer: B
Rationale: The correct answer is B: Mongolian spots. This finding is common in newborns with dark skin and appears as bluish-gray discoloration in areas like the lower back, buttocks, and scrotum. Mongolian spots are benign and typically fade over time. Extensive bruising (A) would present differently and usually indicates trauma. Nevus flammeus (C) refers to a port-wine stain, which is a different type of birthmark. Acrocyanosis (D) is a condition characterized by bluish discoloration of the extremities due to poor circulation, not related to the described finding.
Two days after delivery, a postpartum client prepares for discharge. What should the nurse teach her about lochia flow?
- A. Lochia does change color but goes from lochia rubra (bright red) on days 1-3, to lochia serosa (pinkish brown) on days 4-9, to lochia alba (creamy white) days 10-21.
- B. Numerous clots are abnormal and should be reported to the physician.
- C. Saturation of the perineal pad is considered abnormal and may indicate postpartum hemorrhage.
- D. Lochia normally lasts for about 21 days, and changes from a bright red, to pinkish brown, to creamy white.
Correct Answer: D
Rationale: The correct answer is D. Lochia normally lasts for about 21 days, and changes from a bright red, to pinkish brown, to creamy white. This is accurate information regarding the typical progression of lochia flow postpartum. Lochia rubra is the initial discharge, followed by lochia serosa, and finally, lochia alba. This teaching is important for the client to understand what to expect in terms of postpartum bleeding.
Choice A is incorrect as it inaccurately describes the color changes of lochia. Choice B is incorrect because the presence of numerous clots is common in the immediate postpartum period and not necessarily abnormal. Choice C is incorrect as perineal pad saturation is expected initially, and significant saturation may not always indicate hemorrhage.