A nurse is caring for a client immediately following the delivery of a stillborn fetus. Which of the following actions should the nurse take?
Instruct the client that an autopsy should be performed within 24 hr.
Inform the client that the law requires them to name the fetus.
Provide the client with photos of the fetus.
Limit the amount of time the fetus is in the client's room.
The Correct Answer is C
Rationale:
A. Instructing the client about an autopsy is not the immediate priority and may not be appropriate at this sensitive time.
B. Informing the client about the law regarding naming the fetus is not a priority and may add unnecessary stress to the situation.
C. Providing photos of the fetus is the most appropriate action since it minimzes the trauma to the mother while providing closures.
D. Limiting the amount of time the fetus is in the client's room is not appropriate as when the mother needs more time with the fetus, she hsould be allowed to provide for closure
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Polycythemia: Polycythemia, an elevated red blood cell count, is not typically associated with forceps-assisted birth.
B. Facial palsy:
Correct answer. Facial palsy, or weakness or paralysis of facial muscles, can occur as a complication of forceps-assisted birth due to pressure or trauma to the facial nerve during delivery.
C. Bronchopulmonary dysplasia: Bronchopulmonary dysplasia is a lung condition primarily affecting premature infants and is not directly related to the method of delivery.
D. Hypoglycemia: Hypoglycemia, low blood sugar levels, can occur in newborns for various reasons but is not specifically associated with forceps-assisted birth unless there are other complicating factors.
Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"C"}}
Explanation
Blood pressure 80/50 mm Hg: Indication of Potential Worsening Condition - A decrease in blood pressure may indicate hypovolemic shock due to ongoing or worsening postpartum hemorrhage.
Cloudy urine: Indication of Potential Worsening Condition - Cloudy urine may indicate a urinary tract infection or another complication, which can worsen the client's condition.
Moderate lochia rubra: Indication of Potential Worsening Condition - Continued moderate lochia rubra suggests ongoing or worsening postpartum hemorrhage.
Fundus firm to palpation: Indication of Potential Improvement - A firm fundus suggests effective uterine contraction and control of bleeding, indicating potential improvement.
Fundus at level of umbilicus: Indication of Potential Worsening Condition - The fundus being at the level of the umbilicus suggests uterine atony or continued bleeding, which is a worsening condition.
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