A client at 36 weeks gestation has just delivered a stillborn baby. What should the nurse say?

“You may hold your baby as long as you want.”.

“This is for the best. Your baby was very ill.”.

“I understand your grief. I lost a baby also.”.

“I have called for the chaplain to come and stay with you.”.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Offering the parent the opportunity to hold their stillborn baby can be a crucial part of the grieving process. It allows the parent to acknowledge the reality of the loss and begin to say goodbye.
Choice B rationale
Telling a grieving parent that “this is for the best” can be perceived as dismissive and insensitive. It’s important to validate the parent’s feelings of loss and grief.
Choice C rationale
Sharing personal experiences of loss can shift the focus away from the grieving parent. It’s more helpful to provide empathetic support and allow the parent to share their feelings.
Choice D rationale
While spiritual support can be helpful for some, it’s not appropriate to assume that every parent will want this. It’s better to ask the parent if they would like to speak with a chaplain or other spiritual advisor.

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Correct Answer is ["B","D","E"]

Explanation

Choice A rationale
Restraining a child during a seizure is not recommended. It does not stop the seizure and can lead to injury. The child’s movements during a seizure are involuntary, so trying to stop them can cause harm.
Choice B rationale
Placing the child in a side-lying position is recommended during a seizure. This position helps to prevent aspiration, which can occur if the child vomits during the seizure.
Choice C rationale
It is a common misconception that a person having a seizure can swallow their tongue, but this is not true. Attempting to place a tongue depressor or any other object in the child’s mouth during a seizure can cause injury to the child’s teeth or jaw.
Choice D rationale
Assessing the child’s airway patency is crucial during a seizure. Seizures can cause changes in breathing patterns and can potentially lead to respiratory distress. Therefore, monitoring the child’s breathing during a seizure is important.
Choice E rationale
Removing objects from the child’s bed or surrounding area can help prevent injury during a seizure. During a seizure, the child may have uncontrolled movements, and removing nearby objects can help ensure the child’s safety.

A. A client who has a cesarean incision that is well-approximated with no drainage. B. A client who does not wash her hands between perineal care and breastfeeding. C. A client who has an episiotomy that is erythematous and has extended into a third-degree laceration. D. A client who is not breastfeeding and is using measures to suppress lactation.

Correct Answer is C

Explanation

Choice A rationale
A client who has a cesarean incision that is well-approximated with no drainage is not at the greatest risk for developing a puerperal infection. While any surgical incision can potentially become infected, if the incision is healing well with no signs of infection, the risk is relatively low.
Choice B rationale
A client who does not wash her hands between perineal care and breastfeeding is increasing her risk of infection, but this is not the greatest risk factor for developing a puerperal infection. Good hand hygiene is important to prevent the spread of germs, but other factors pose a greater risk for puerperal infection.
Choice C rationale
A client who has an episiotomy that is erythematous and has extended into a third-degree laceration is at the greatest risk for developing a puerperal infection. An episiotomy is a surgical cut made at the opening of the vagina during childbirth to aid a difficult delivery and prevent rupture of tissues. If the episiotomy extends and becomes a third-degree laceration, it involves the vaginal tissue, perineal skin, and the muscle of the perineum, and can extend into the anal sphincter, the muscle that surrounds the anus. This type of wound provides a medium for bacterial growth, increasing the risk of infection.
Choice D rationale
A client who is not breastfeeding and is using measures to suppress lactation is not at the greatest risk for developing a puerperal infection. While breastfeeding can help reduce the risk of certain types of infections, not breastfeeding does not significantly increase the risk of puerperal infection.

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A client at 36 weeks gestation has just delivered a stillborn baby. What should the nurse say?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who is having a seizure. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

A nurse is providing care to multiple clients on the postpartum unit. Which of the following clients is at the greatest risk for developing a puerperal infection?

Correct Answer is C

Explanation

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