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, an elevated red blood cell count, is not typically associated with forceps- assisted birth.
B. Facial palsy, or facial nerve injury, can occur as a complication of forceps-assisted birth due to pressure on the facial nerves during delivery.
C. Bronchopulmonary dysplasia is a lung condition primarily associated with premature birth and prolonged mechanical ventilation, not forceps-assisted birth.
D. Hypoglycemia may occur in newborns for various reasons but is not specifically associated with forceps-assisted birth unless there are other complicating factors such as maternal diabetes.
Correct Answer is C
Explanation
Rationale:
A. Using a 21-gauge needle may be too large for a newborn, increasing the risk of discomfort and tissue damage.
B. Inserting the needle at a 45° angle may not be appropriate for intramuscular injections in newborns. The preferred angle is typically 90°.
C. Administering the injection into the vastus lateralis muscle is the recommended site for hepatitis B vaccination in newborns. This site is located on the anterior lateral aspect of the thigh and provides good muscle mass for injection.
D. Vigorously massaging the site following the injection is not recommended as it may increase discomfort and tissue trauma. Instead, gentle pressure can be applied to the site to help reduce discomfort.
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