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 and aids in the grieving process. It can provide closure and help in acknowledging the loss. Choice A may not be necessary if the client desires more time with the fetus. Choice C about an autopsy is not necessary unless the client consents. Choice D is incorrect as there is no law requiring the client to name the fetus.
You may also like to solve these questions
A nurse is assessing a client who is 3 days postpartum. Which of the following findings should the nurse report to the provider?
- A. Cool, clammy skin
- B. Moderate lochia serosa
- C. Heart rate 89/min
- D. BP 120/70 mm Hg
Correct Answer: A
Rationale: The correct answer is A: Cool, clammy skin. This finding could indicate hypovolemic shock, a serious postpartum complication. The nurse should report this to the provider immediately for further evaluation and intervention to prevent deterioration. Moderate lochia serosa (B) is expected 3 days postpartum. Heart rate of 89/min (C) and BP of 120/70 mm Hg (D) are within normal range for a postpartum client and do not require immediate reporting.
Which of the following findings should the nurse report to the provider? Select all that apply.
- A. Respiratory findings
- B. Oxygen saturation
- C. Central nervous system findings
- D. Gastrointestinal findings
Correct Answer: C,D
Rationale: The nurse should report central nervous system (CNS) and gastrointestinal (GI) findings to the provider because changes in these systems can indicate serious health issues. CNS findings may suggest neurological problems, while GI findings could indicate digestive issues or potential complications. Reporting these findings promptly allows the provider to assess the patient's condition thoroughly and intervene if necessary. Respiratory and oxygen saturation findings are important but may not always require immediate intervention. Other choices are not directly related to critical health concerns that need urgent attention.
A nurse is reviewing the prescriptions for a client who is pregnant and is taking digoxin. Which of the following actions should the nurse take to best evaluate the client’s medication adherence?
- A. Ask the client if they are taking the medication as prescribed.
- B. Assess the client’s kidney function.
- C. Determine the client’s apical pulse rate.
- D. Check the client’s serum medication level.
Correct Answer: D
Rationale: The correct answer is D: Check the client's serum medication level. This is the best way to evaluate medication adherence for a client taking digoxin. Digoxin has a narrow therapeutic range, so checking the serum level helps determine if the client is taking the medication as prescribed. If the level is within the therapeutic range, it indicates adherence. Asking the client if they are taking the medication (A) relies on self-reporting, which may not be accurate. Assessing kidney function (B) and determining apical pulse rate (C) are important for monitoring digoxin therapy but do not directly assess medication adherence. Checking the serum medication level provides objective data to confirm adherence.
A nurse is admitting a client to the labor and delivery unit when the client states, 'My water just broke.' Which of the following interventions is the nurse's priority?
- A. Perform Nitrazine testing.
- B. Assess the fluid.
- C. Check cervical dilation.
- D. Begin FHR monitoring.
Correct Answer: D
Rationale: The correct answer is D: Begin FHR monitoring. This is the priority because the client's water breaking indicates a potential risk to the fetus, such as umbilical cord compression or prolapse. FHR monitoring helps assess fetal well-being and detect any signs of distress. Performing Nitrazine testing (A) and checking cervical dilation (C) can wait until after ensuring fetal safety. Assessing the fluid (B) may provide some information but does not directly address the immediate concern for fetal well-being.
A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan?
- A. Feed the newborn 1 oz of water every 4 hr.
- B. Apply lotion to the newborn's skin three times per day.
- C. Remove all clothing from the newborn except the diaper.
- D. Discontinue therapy if the newborn develops a rash.
Correct Answer: C
Rationale: The correct answer is C: Remove all clothing from the newborn except the diaper. This is important because phototherapy requires direct exposure of the newborn's skin to the light source to effectively reduce bilirubin levels. Clothing can block the light and decrease the effectiveness of the therapy. It is essential to maximize skin exposure during phototherapy.
Choice A is incorrect because feeding water is not directly related to phototherapy for hyperbilirubinemia. Choice B is incorrect as applying lotion can interfere with the effectiveness of the therapy by creating a barrier between the skin and the light source. Choice D is incorrect because a rash is a common side effect of phototherapy and does not necessarily require discontinuation of the therapy.