A nurse is caring for a client who just delivered a stillborn infant at 36 weeks gestation.
Which of the following responses should the nurse make?
I understand your grief. I lost a baby also.
I have called for the chaplain to come and stay with you.
You may hold your baby as long as you want.
This is for the best. Your baby was very ill.
The Correct Answer is C
Choice A rationale
While sharing personal experiences can sometimes be comforting, it may not always be appropriate or helpful in a professional setting. The focus should be on the patient’s needs and feelings.
Choice B rationale
Calling for a chaplain can be supportive, but it is important to first offer the parents the opportunity to hold their baby and spend time with them, which can be an important part of the grieving process.
Choice C rationale
Allowing the parents to hold their baby for as long as they want provides them with the opportunity to say goodbye and can be a crucial part of the grieving process. It helps them to acknowledge their loss and begin to process their emotions.
Choice D rationale
Telling the parents that the loss is for the best is not supportive and can be hurtful. It is important to validate their feelings and provide compassionate care during this difficult time. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Obtaining a prescription for an antibiotic is not the first recommendation for a client who is 3 days postpartum and breastfeeding with hard and warm breasts. Antibiotics are typically prescribed if there is a confirmed infection, such as mastitis, which is characterized by symptoms like fever, chills, and flu-like symptoms. In this case, the client is experiencing normal postpartum breast engorgement, which does not require antibiotics.
Choice B rationale
Expressing milk from both breasts is the correct recommendation. Breast engorgement is common in the early postpartum period as the milk comes in. Expressing milk, either by breastfeeding frequently or using a breast pump, helps to relieve the fullness, reduce discomfort, and maintain milk production.
Choice C rationale
Wearing a nipple shield is not recommended for breast engorgement. Nipple shields are typically used for issues like latch difficulties or sore nipples, not for relieving engorgement. Using a nipple shield without proper guidance can potentially interfere with milk transfer and breastfeeding success.
Choice D rationale
Applying a heating pad to the breasts is not recommended for engorgement. Heat can increase blood flow and exacerbate swelling. Instead, cold compresses or cold cabbage leaves are often recommended to reduce swelling and discomfort associated with engorgement.
Correct Answer is B
Explanation
Choice B rationale
A heart rate of 110/min is a sign of tachycardia, which can indicate a postpartum complication such as infection, hemorrhage, or other underlying conditions. Tachycardia requires immediate assessment and intervention.
Choice A rationale
Chills shortly following delivery can be a normal response to the body’s adjustment after childbirth and do not necessarily indicate a complication.
Choice C rationale
Urinary output of 3,000 mL/12 hr is high but can be a normal part of postpartum diuresis as the body eliminates excess fluid accumulated during pregnancy.
Choice D rationale
The fundus at the umbilicus level is a normal finding in the immediate postpartum period and does not indicate a complication.
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