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.

Answer and Explanation

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. .

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Correct Answer is B

Explanation

Choice A rationale

Placing the client on seizure precautions is not appropriate for shaking chills during the immediate postpartum period. Shaking chills are a common physiological response after childbirth due to hormonal changes and the body’s effort to regulate temperature. Seizure precautions are reserved for clients with a history of seizures or those exhibiting signs of a seizure disorder.

Choice B rationale

Covering the client with warm blankets is the correct action. Shaking chills are often due to the body’s attempt to regain thermal balance. Providing warmth with blankets helps to alleviate the chills and provide comfort to the client.

Choice C rationale

Determining the client’s temperature is important but not the immediate action to take. While it is necessary to monitor for fever, which could indicate an infection, the priority is to provide comfort and warmth to the client experiencing chills.

Choice D rationale

Notifying the charge nurse is not the immediate action required. The nurse should first address the client’s immediate need for warmth and comfort. If the chills persist or are accompanied by other concerning symptoms, then notifying the charge nurse would be appropriate.

A. An indication of a cervical or perineal laceration. B. Abnormally excessive lochia rubra flow. C. A normal postural discharge of lochia. D. Evidence of a possible vaginal hematoma.

Correct Answer is C

Explanation

Choice A rationale

A cervical or perineal laceration would typically result in continuous bleeding rather than a gush that stops. The uterus would also not be firm and midline if there were a significant laceration.

Choice B rationale

Abnormally excessive lochia rubra flow would be continuous and not stop after a gush. The uterus being firm and midline indicates that the bleeding is not excessive.

Choice C rationale

A normal postural discharge of lochia occurs when pooled blood in the vagina is expelled upon standing or changing position. This is common and expected in the postpartum period.

Choice D rationale

A vaginal hematoma would present with localized pain and swelling, and the bleeding would not stop suddenly. The uterus being firm and midline also indicates that a hematoma is unlikely.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is experiencing shaking chills during the immediate postpartum period.Which of the following actions should the nurse take?

Correct Answer is B

Explanation

During ambulation to the bathroom, a postpartum client experiences a gush of dark red blood that soon stops.On data collection, a nurse finds the uterus to be firm, midline, and at the level of the umbilicus.Which of the following findings should the nurse interpret this data as being?

Correct Answer is C

Explanation

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?

A nurse is collecting data from a client who is 3 hr postpartum.The nurse notes that the client’s fundus is displaced to the right of midline, is firm, and is two fingerbreadths above the umbilicus.Which of the following actions should the nurse take?

A new mother who is bottle feeding says that she is happy to not have to use birth control for several months after having a baby.What should the nurse say in response?

After a client has a C-section she needs to get up and take short walks to prevent what?

A nurse is caring for a client who is 2 weeks postpartum.The client tells the nurse, “I feel really down and sad lately.I have no energy and I feel like I’m going to cry.”. Which of the following actions should the nurse take first?

In your patients who have sustained an episiotomy or a laceration, your nursing care would include? (Select all that apply.)

A nurse is collecting data from a postpartum client and finds a large amount of lochia rubra with several clots on the client’s perineal pad.Which of the following actions should the nurse take first?

A nurse is collecting data from a client who is 12 hours postpartum following a spontaneous vaginal delivery.The nurse should expect to find the uterine fundus at which of the following positions on the client’s abdomen?

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?