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
A. While an autopsy can be an option for determining the cause of stillbirth, it is not a requirement, and the decision should be made by the parents. This statement may add undue pressure on the client.
B. There is no legal requirement for parents to name a stillborn fetus. This can be a sensitive topic, and it is essential to respect the parents' wishes and feelings in this regard.
C. Providing the client with photos of the fetus can help the parents in their grieving process, allowing them to create memories and acknowledge their loss. This action can offer emotional support and validation of their experience.
D. Limiting the time the fetus is in the client's room may not consider the parents' need for closure and the opportunity to say goodbye. Encouraging the family to spend time with their stillborn child can be an important aspect of the grieving process.
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Related Questions
Correct Answer is C
Explanation
Rationale:
A. "When was the last time you ate meat?": This question is not relevant for a client who adheres to a vegan diet, as they do not consume meat.
B. "Have you considered eating shellfish?": This question is not appropriate for a client who follows a vegan diet, as shellfish is not part of a vegan diet.
C. "How much protein do you eat in a day?":
Correct answer. Protein intake is an important consideration for individuals following a vegan diet, as they may need to ensure they are obtaining adequate protein from plant-based sources.
D. "Are you taking a Vitamin C supplement?": While assessing vitamin intake is important, protein intake is particularly relevant for a client following a vegan diet, as certain plant-based protein sources may be lower in certain essential amino acids compared to animal-based protein sources.
Correct Answer is D
Explanation
Rationale:
A. Administering oxygen via a nonrebreather mask may be indicated for fetal distress, but the priority in this situation is to protect the umbilical cord from compression and minimize fetal compromise.
B. Cover the umbilical cord with a sterile saline-saturated towel is an appropriate action to prevent the cord from drying out and to reduce infection butimmediate focus should be on relieving pressure on the umbilical cord to ensure adequate fetal perfusion.
C. Initiate an infusion of IV fluids for the client can help stabilize maternal hemodynamics, but it does not directly address the umbilical cord compression. Relieving the pressure on the cord is the immediate intervention to prevent fetal hypoxia.
D. Perform a vaginal examination by applying upward pressure on the presenting part is the priority intervention. In cases of umbilical cord prolapse, the nurse must perform a vaginal examination and apply upward manual pressure on the presenting part (usually the fetal head) to lift it off the umbilical cord. This action relieves compression on the cord and restores blood flow and oxygen delivery to the fetus until an emergency delivery can be performed.
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