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.

Answer and Explanation

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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Correct Answer is C

Explanation

Rationale:

A. Administering methylergonovine is not appropriate for a fourth-degree perineal laceration.

Methylergonovine is typically used to prevent or treat postpartum hemorrhage by promoting uterine contractions.

B. Applying povidone-iodine to the client's perineum is not indicated for the management of a perineal laceration. Povidone-iodine is an antiseptic solution used for wound cleansing, but it may be too harsh for the perineal area.

C. Providing the client with a cool sitz bath is appropriate for managing discomfort and promoting healing after a fourth-degree perineal laceration. A sitz bath helps to soothe the perineal area and reduces inflammation.

D. Applying a moist, warm compress to the perineum is not recommended for a fourth-degree perineal laceration, as it may increase the risk of infection and discomfort.

A. Assist the client in pulling their knees toward their abdomen. B. Apply pressure to the client's fundus. C. Press firmly on the client's suprapubic area. D. Move the client onto their hands and knees.

Correct Answer is A

Explanation

Rationale:

A. The McRoberts maneuver involves flexing the mother's thighs onto her abdomen to straighten the pelvis and allow for easier passage of the baby's shoulder. This action helps to widen the pelvic outlet and facilitate delivery.

B. Applying pressure to the client's fundus is not part of the McRoberts maneuver. Fundal pressure may be used in other techniques to manage shoulder dystocia, such as the Rubin maneuver or Woods' screw maneuver.

C. Pressing firmly on the client's suprapubic area is not part of the McRoberts maneuver. This action may be performed in conjunction with other maneuvers to help dislodge the impacted shoulder.

D. Moving the client onto their hands and knees is not part of the McRoberts maneuver. This position, known as the Gaskin maneuver, may be used as an alternative maneuver to alleviate shoulder dystocia by changing the orientation of the pelvis.

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A nurse is caring for a client immediately following the delivery of a stillborn fetus. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 12 hr postpartum and has a fourth-degree laceration of the perineum. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client who is in the second stage of labor and is experiencing a shoulder dystocia. The provider instructs the nurse to perform the McRoberts maneuver. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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