The nurse is caring for a client whose fetus died in utero at 32-weeks gestation. After the fetus is delivered vaginally, the nurse implements routine fetal demise protocol and identification procedures Which action is most important for the nurse to take?

Explain reasons consent for an infant autopsy is needed

Determine if the mother desires a visit from her clergy

Encourage the mother to hold and spend time with her baby

Create a memory box of baby's footprints and photographs

Answer and Explanation

The Correct Answer is C

Explain reasons consent for an infant autopsy is needed:
Autopsy might be necessary for understanding the cause of fetal demise, providing answers to the parents, and helping future pregnancies. However, it's not the most immediate or essential action in this scenario.

Determine if the mother desires a visit from her clergy:
Spiritual and emotional support is crucial during this distressing time. While clergy support is valuable, it's not the most urgent action needed immediately after delivery.

Encourage the mother to hold and spend time with her baby:
This is a crucial part of the grieving process and helps in acknowledging and creating memories with the baby. It's an essential step in providing emotional support to the mother.

Create a memory box of baby's footprints and photographs:
This is also a critical step in assisting the parents with the grieving process. It helps in cherishing the memories and creating keepsakes that may provide comfort in the future.

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Correct Answer is ["C","D","E"]

Explanation

A. Place client in a negative pressure room:HIV is not an airborne disease, and clients with HIV do not require isolation in a negative pressure room. Standard precautions are sufficient to prevent transmission.

B. Implement droplet precautions:HIV is not transmitted via droplets. It is transmitted through contact with blood, certain body fluids, or perinatal exposure. Droplet precautions are not indicated.

C. Encourage the mother to bottle-feed: HIV can be transmitted through breast milk. To prevent vertical transmission postpartum, mothers with HIV are advised to avoid breastfeeding and to use formula or bottle-feed instead.

D. Give antiviral medication intravenously: Intrapartum IV zidovudine should be administered in the following situations: (a) HIV RNA >1,000 copies/mL, (b) unknown HIV RNA, (c) known or suspected lack of adherence since the last HIV RNA result, or (d) a positive expedited antigen/antibody HIV test result during labor (AI).

E. Use standard precautions:Standard precautions are the appropriate infection control measures for caring for clients with HIV. This includes wearing gloves, practicing proper hand hygiene, and avoiding contact with the client's blood and other potentially infectious fluids.

A. Review the fetal heart rate pattern B. Check the pH of the vaginal fluid C. Determine cervical dilation. D. Palpate the client's bladder

Correct Answer is D

Explanation

A. Review the fetal heart rate pattern: Checking the fetal heart rate (FHR) pattern is crucial during labor to ensure the baby is tolerating labor well and there are no signs of fetal distress. However, when the client expresses a need to use the bathroom, this may not be the immediate action required.

B. Check the pH of the vaginal fluid: Checking the pH of the vaginal fluid is not typically an initial action when a laboring client expresses a need to go to the bathroom. Monitoring the pH may be relevant for various reasons, but it's not a primary consideration in this context.

C. Determine cervical dilation: The initial examination revealed the cervix was 3 cm dilated. While reassessing the cervical dilation could provide information about the progress of labor, it may not be the most immediate action needed when the client wants to use the bathroom.

D. Palpate the client's bladder: This is the most relevant action when a laboring client expresses a desire to go to the bathroom. Palpating the bladder can help determine if it's full, which is important because a full bladder might impede labor progress or cause discomfort during contractions.

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The nurse is caring for a client whose fetus died in utero at 32-weeks gestation. After the fetus is delivered vaginally, the nurse implements routine fetal demise protocol and identification procedures Which action is most important for the nurse to take?

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Naxlex Comprehensive Predictor Exams

A client at 40-weeks gestation is admitted in active labor, and laboratory findings indicate that she is HIV positive. Which actions should the nurse plan to perform? (Select all that apply.)

Correct Answer is ["C","D","E"]

Explanation

The nurse examines a client who is admitted in active labor and determines the cervix is 3 cm dilated 50% effaced, and the presenting part is at 0 station. An hour later. she tells the nurse that she wants to go to the bathroom. Which action should the nurse implement first?

Correct Answer is D

Explanation

A nurse is speaking with a client who is addicted to heroin and who just learned that she is pregnant. The client states, "I just started taking methadone. Is there anything else I can do to make sure my baby is healthy? Which information should the nurse provide?

Which physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?

What is the most important assessment for the nurse to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation?

The nurse is caring for a client whose fetus died in utero at 32-weeks gestation. After the fetus is delivered vaginally, the nurse implements routine fetal demise protocol and identification procedures Which action is most important for the nurse to take?

A client who is 32 weeks gestation comes to the women's health clinic and reports nausea and vomiting. On examination, the nurse notes that the client has an elevated blood pressure. Which action should the nurse implement next?

A client at 40-weeks gestation presents to the obstetrical floor and indicates that the amniotic membranes ruptured spontaneously at home. She is in active labor, and feels the need to bear down and push. Which information is most important for the nurse to obtain?

A client who delivered vaginally 2 days ago states that she wants to resume using her diaphragm for birth control. What information should the nurse share with her?

Which type of anesthesia, used with a client in labor, produces a loss of sensation only to the vagina and perineum?