A nurse is developing a plan of care for a client who delivered a stillborn fetus following a placental abruption. Which of the following interventions should the nurse include?

Talk about the special features of the baby with the client.

Post a sign indicating No Visitors.

Limit the amount of time the client is allowed to have the baby in her room.

Tell the parents they should hold their baby.

Answer and Explanation

The Correct Answer is A

A) Talk about the special features of the baby with the client: This intervention acknowledges the baby as a real person and can provide comfort to the grieving parents by validating their loss and giving them a chance to create memories, which is an important aspect of the grieving process.

B) Post a sign indicating No Visitors: This may not be appropriate as it might isolate the client further. Some parents may want the support of family and friends during this difficult time, and such a restriction should be based on the parents' wishes rather than a standard protocol.

C) Limit the amount of time the client is allowed to have the baby in her room: Allowing parents to spend as much time as they need with their baby can help them with the grieving process. Placing limits might be perceived as insensitive and could hinder the emotional healing process.

D) Tell the parents they should hold their baby: While many parents find comfort in holding their stillborn baby, it should be offered as a choice rather than a directive. It is important to respect the parents' individual coping mechanisms and provide support based on their preferences.

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Correct Answer is A

Explanation

A) "Monitor for manifestations of hypoglycemia":
Glipizide is a sulfonylurea, which works by increasing insulin secretion from the pancreas. This can lower blood glucose levels, potentially leading to hypoglycemia. Therefore, it's essential for the client to be aware of and monitor for symptoms such as sweating, shakiness, confusion, and dizziness to manage and treat hypoglycemia promptly.

B) "Take this medication at bedtime":
Glipizide is typically taken before meals to stimulate insulin secretion in response to food intake, helping control postprandial blood glucose levels. Taking it at bedtime is not recommended as it might not be as effective and could increase the risk of nighttime hypoglycemia.

C) "Weigh yourself weekly to monitor for weight loss":
While weight monitoring is important for managing diabetes, glipizide does not commonly cause weight loss. In fact, it may sometimes lead to weight gain. Therefore, this instruction is less relevant than monitoring for hypoglycemia.

D) "Plan to continue to take over-the-counter medications as needed":
Over-the-counter medications can interact with glipizide, potentially affecting blood glucose levels or increasing the risk of side effects. The client should consult with their healthcare provider before taking any new medications. This instruction does not address the primary concern of hypoglycemia management.

A. "Tilt the spirometer toward yourself so you can see the balls rise." B. "Inhale deeply and hold each breath for a minimum of 10 seconds." C. "Exhale before sealing your lips around the mouthpiece." D. "Use your incentive spirometer every 4 hours while you are awake."

Correct Answer is D

Explanation

A) "Tilt the spirometer toward yourself so you can see the balls rise": Tilting the spirometer is not necessary and may affect its accuracy. The spirometer should be held in an upright position to ensure correct measurement of inhalation.

B) "Inhale deeply and hold each breath for a minimum of 10 seconds": Inhaling deeply is important, but holding each breath for 10 seconds is not a typical recommendation for using an incentive spirometer. The goal is to inhale deeply and slowly, without necessarily holding the breath for an extended period.

C) "Exhale before sealing your lips around the mouthpiece": Exhaling before using the spirometer is not recommended. The correct procedure involves inhaling deeply and slowly after sealing your lips around the mouthpiece to ensure accurate measurement and effective lung expansion.

D) "Use your incentive spirometer every 4 hours while you are awake": Frequent use of the incentive spirometer, often every hour while awake, is recommended to improve lung function and prevent complications such as atelectasis. Using it every 4 hours may not be sufficient for effective respiratory therapy.

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A nurse is developing a plan of care for a client who delivered a stillborn fetus following a placental abruption. Which of the following interventions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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