A nurse is caring for a client following a vaginal delivery of a term fetal demise. Which of the following statements should the nurse make?

"You can bathe and dress your baby if you'd like to."

"You should name the baby so she can have an identity."

"I'm sure you will be able to have another baby when you're ready."

"If you don't hold the baby, it will make letting go much harder."

Answer and Explanation

The Correct Answer is A

A. "You can bathe and dress your baby if you'd like to."
This statement gives the client the option to spend time with their baby if they wish to do so. It respects the client's autonomy and choice in how they want to handle this difficult situation.

B. Telling the client to name the baby may put unnecessary pressure on them during a challenging time.

C. Assuring the client that they can have another baby in the future might not be comforting at this moment, as they are grieving the loss of their current pregnancy.

D. Pressuring the client to hold the baby may not be appropriate, as everyone's grief process is different, and the client should be allowed to make their own choices regarding physical contact with the baby.

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Correct Answer is ["A","B","C","D"]

Explanation

Performing fundal massage for a postpartum client with uterine atony should be done in the following order:
Ask the client to lie on her back and with her knees flexed.

Placing the client in the supine position with knees flexed helps relax the abdominal muscles and facilitates access to the uterus.

Position one hand around the top of the client's fundus and one hand just above the client's symphysis pubis.

This step involves proper hand placement to locate and assess the position of the uterus.

Rotate the upper hand to massage the client's uterus while using slight downward pressure to compress the fundus.

After proper hand placement, you can start the fundal massage with a rotating motion using slight downward pressure. This helps stimulate uterine contractions and control bleeding.

Observe the client's perineum for the passage of clots and the amount of bleeding.

While massaging the uterus, it's essential to monitor the client's perineum for any signs of excessive bleeding or clot passage.

So, the correct order is: Ask the client to lie on her back and with her knees flexed > Position one hand around the top of the client's fundus and one hand just above the client's symphysis pubis > Rotate the upper hand to massage the client's uterus while using slight downward pressure to compress the fundus > Observe the client's perineum for the passage of clots and the amount of bleeding.

A. Moderate variability of the fetal heart rate B. Nonrepetitive early decelerations C. Six contractions in 10 min D. Contractions last 60 seconds

Correct Answer is D

Explanation

A. "Moderate variability of the fetal heart rate" is a reassuring sign, indicating that the fetus is tolerating labor well. It does not warrant discontinuing oxytocin.

B. "Nonrepetitive early decelerations" are also a reassuring sign and are typically not an indication to discontinue oxytocin. Early decelerations are typically benign and related to head compression during contractions.

C. "Six contractions in 10 min" may be within the acceptable range for uterine activity during labor. However, it's important to assess the duration and intensity of these contractions as well.

D. "Contractions last 60 seconds" on their own may not be an indication to discontinue oxytocin. The nurse should also assess the frequency and intensity of contractions to determine if they are causing uterine hyperstimulation. Uterine Hyperstimulation Occurs: Uterine hyperstimulation is defined by an excessive frequency, duration, or intensity of contractions. Generally, contractions that occur more frequently than 5 contractions in 10 minutes (one every 2 minutes) or contractions that last longer than 60-90 seconds can be concerning.

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A nurse is caring for a client following a vaginal delivery of a term fetal demise. Which of the following statements should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to perform a fundal massage for a postpartum client who is experiencing uterine atony. In which order should the nurse plan to perform the following actions? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is ["A","B","C","D"]

Explanation

A nurse is caring for a client who is receiving oxytocin to induce labor. The nurse should discontinue the oxytocin if which of the following occurs?

Correct Answer is D

Explanation

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