A nurse is caring for a patient immediately following the delivery of a stillborn fetus. What action should the nurse take?
Provide the patient with photos of the fetus.
Instruct the patient that an autopsy should be performed within 24 hours.
Limit the amount of time the fetus is in the patient’s room.
Inform the patient that the law requires them to name the fetus.
The Correct Answer is A
Choice A rationale
Providing the patient with photos of the fetus can be a part of memory-making and is often a key component of care after a stillbirth. It allows parents to remember their baby and can aid in the grieving process.
Choice B rationale
While an autopsy can provide information about why a stillbirth occurred, it is not mandatory and should be discussed with the parents. The decision to perform an autopsy should be based on the parents’ wishes.
Choice C rationale
Limiting the amount of time the fetus is in the patient’s room is not necessarily beneficial. Some parents may want to spend time with their baby to say goodbye, which can be therapeutic.
Choice D rationale
Informing the patient that the law requires them to name the fetus is not accurate. The decision to name the fetus is a personal one and varies among individuals.
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Correct Answer is D
Explanation
The correct answer is choice d. Transmission can occur via the saliva and urine of the newborn.
Choice A rationale:
Lesions are not typically visible on the mother’s genitalia with cytomegalovirus (CMV) infection. CMV is often asymptomatic or presents with nonspecific symptoms, and visible lesions are not a characteristic feature.
Choice B rationale:
CMV does not require airborne precautions. It is primarily transmitted through direct contact with bodily fluids such as saliva, urine, blood, and breast milk.
Choice C rationale:
Prophylactic treatment with acyclovir is not standard for CMV. Acyclovir is used for herpes simplex virus infections, not CMV.
Choice D rationale:
CMV can indeed be transmitted via the saliva and urine of the newborn. This is a common mode of transmission, especially in settings like daycare centers where young children are in close contact.
Correct Answer is D
Explanation
The correct answer is choice d. Assist the client to the bathroom.
Choice A rationale:
Inserting a urinary catheter is an invasive procedure and should be considered only after less invasive measures have been attempted and failed. It carries risks such as infection and trauma to the urethra.
Choice B rationale:
Pouring warm water over the client’s perineum can help stimulate urination, but it should be tried after assisting the client to the bathroom. It is a non-invasive method but not the first action to take.
Choice C rationale:
Offering a sitz bath can also help with urination by relaxing the perineal muscles, but it is not the first action to take. It is more appropriate if the client is unable to void after trying to use the bathroom.
Choice D rationale:
Assisting the client to the bathroom is the least invasive and most straightforward initial action. It allows the client to attempt to void naturally, which is preferable before trying other interventions.
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