Nokea
A nurse is caring for a client immediately following the delivery of a stillborn fetus. Which of the following actions should the nurse take?
- A. Limit the amount of time the fetus is in the client’s room.
- B. Provide the client with photos of the fetus.
- C. Instruct the client that an autopsy should be performed within 24 hr.
- D. Inform the client that the law requires them to name the fetus.
Correct Answer: B
Rationale: The correct answer is B: Provide the client with photos of the fetus. This action allows the client to have tangible memories of their stillborn baby, aiding in the grieving process and closure. It acknowledges the baby's existence and validates the client's experience. Choice A may be incorrect as it could deprive the client of the opportunity to spend time with their baby for closure. Choice C is incorrect as it may not be necessary in all cases and could be overwhelming for the client. Choice D is incorrect as there is no legal requirement to name a stillborn fetus.
You may also like to solve these questions
Select the 3 findings that require immediate follow-up.
- A. Lateral deviation of the uterus
- B. Deep tendon reflexes 1+
- C. Pain rating of 3 on a scale of 0 to 10 (increased)
- D. Peripheral edema 2+ bilateral lower extremities
- E. Uterine tone soft
- F. Large amount of lochia rubra
- G. Blood pressure 136/86 mm Hg
Correct Answer: A,B,C
Rationale: The correct answers are A, B, and C. A lateral deviation of the uterus could indicate a potential complication such as uterine inversion. Deep tendon reflexes being 1+ may suggest hyporeflexia, which could be a sign of neurological issues. A pain rating of 3 on a scale of 0 to 10, especially if increased, may indicate worsening pain that needs immediate attention. Choices D, E, F, and G do not require immediate follow-up as they are not indicative of urgent conditions. Peripheral edema 2+ bilateral lower extremities may be normal postpartum. Uterine tone being soft is expected in the postpartum period. A large amount of lochia rubra is typically seen in the immediate postpartum period. Blood pressure of 136/86 mm Hg is within normal limits for a postpartum patient.
A nurse is assessing a newborn who has neonatal abstinence syndrome. Which of the following findings should the nurse expect?
- A. Diminished deep tendon reflexes
- B. Excessive crying
- C. Decreased muscle tone
- D. Absent Moro reflex
Correct Answer: B
Rationale: The correct answer is B: Excessive crying. Neonatal abstinence syndrome is characterized by symptoms such as irritability, high-pitched crying, tremors, and poor feeding due to withdrawal from substances the mother used during pregnancy. Excessive crying is a common manifestation of this syndrome. Diminished deep tendon reflexes (A), decreased muscle tone (C), and absent Moro reflex (D) are not typically associated with neonatal abstinence syndrome. These findings may indicate other neurological or developmental issues.
A nurse is caring for a client who is 48 hr postpartum and has a deep vein thrombosis.
- A. Increased warmth in the extremity
- B. Tachycardia
- C. Leukocytosis
- D. Scant lochia rubra
- E. Decreased extremity edema
Correct Answer:
Rationale: Correct Answer:
Rationale:
1. Increased warmth in the extremity: This is a key finding in deep vein thrombosis indicating inflammation and potential clot progression.
2. Tachycardia: Indicative of the body's response to a clot, signifying a worsening condition.
3. Leukocytosis: Elevated white blood cell count suggests an inflammatory response, further confirming a worsening condition.
Summary:
- Scant lochia rubra: Not directly related to deep vein thrombosis, less relevant in this context.
- Decreased extremity edema: While it could indicate improvement, it is not specific to deep vein thrombosis and may not be a reliable indicator.
A nurse is assessing a newborn whose mother had gestational diabetes mellitus. The nurse should monitor for which of the following findings as a manifestation of hypoglycemia?
- A. Abdominal distention
- B. Petechiae
- C. Increased muscle tone
- D. Jitteriness
Correct Answer: D
Rationale: The correct answer is D: Jitteriness. Infants born to mothers with gestational diabetes are at risk for hypoglycemia due to the abrupt cessation of the maternal glucose supply post-birth. Jitteriness is a common manifestation of hypoglycemia in newborns, indicating the need for prompt intervention to prevent further complications. Abdominal distention (A) is not typically associated with hypoglycemia. Petechiae (B) are small red or purple spots on the skin caused by bleeding under the skin and are not directly related to hypoglycemia. Increased muscle tone (C) is not a typical sign of hypoglycemia in newborns.
A nurse is teaching about home safety with a client who is 2 days postpartum. Which of the following instructions should the nurse include in the teaching?
- A. Bathe your baby immediately after a feeding.
- B. Place a bumper pad in your baby’s crib.
- C. Put a soft mattress in your baby’s crib.
- D. Wash your baby’s face with plain water.
Correct Answer: D
Rationale: The correct answer is D: Wash your baby's face with plain water. This instruction is important because newborns have sensitive skin that can easily become irritated by soaps or cleansers. Using plain water is gentle and safe for the baby's delicate skin. Additionally, washing the baby's face helps to keep the area clean and prevent any buildup of milk or debris that can lead to skin irritation or infections.
Choice A is incorrect because bathing a baby immediately after a feeding can increase the risk of spitting up or discomfort due to handling on a full stomach. Choice B is incorrect as bumper pads pose a suffocation risk for infants. Choice C is incorrect because a soft mattress can increase the risk of Sudden Infant Death Syndrome (SIDS).