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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 child, which can aid in the grieving process and provide closure. Providing photos is a sensitive and compassionate gesture that acknowledges the significance of the loss. It also respects the client's autonomy in choosing how they wish to remember their child.
The other choices are not appropriate in this situation:
A: Limiting the time the fetus is in the room may not consider the emotional needs of the client.
C: Instructing the client about an autopsy may be insensitive and distressing without discussing it first with the client.
D: Informing the client about naming the fetus is not a legal requirement and could add unnecessary pressure during a difficult time.
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A nurse is reviewing the chart of a client who is 2 days postpartum following a vaginal delivery and reports constipation. Which of the following findings should the nurse identify as a contraindication to the use of a suppository?
- A. Vaginal candidiasis
- B. Abdominal distention
- C. Afterpains
- D. Third-degree perineal laceration
Correct Answer: D
Rationale: The correct answer is D: Third-degree perineal laceration. Using a suppository in a client with a third-degree perineal laceration can increase the risk of infection or further trauma to the area. It is crucial to allow the laceration to heal properly without introducing any foreign substances.
A: Vaginal candidiasis - This is not a contraindication to using a suppository for constipation.
B: Abdominal distention - This is not a contraindication to using a suppository for constipation.
C: Afterpains - This is not a contraindication to using a suppository for constipation.
In summary, the other choices do not directly impact the safety or effectiveness of using a suppository for constipation postpartum, making them incorrect options.
A nurse is caring for a client who is at 37 weeks of gestation and is being tested for group B streptococcus ß-hemolytic (GBS). The client is multigravida and multipara with no history of GBS. She asks the nurse why the test was not conducted earlier in her pregnancy. Which of the following is an appropriate response by the nurse?
- A. You didn't report any symptoms of GBS during your pregnancy.'
- B. Your previous deliveries were all negative for GBS.'
- C. There was no indication of GBS in your earlier prenatal testing.'
- D. We need to know if you are positive for GBS at the time of delivery.'
Correct Answer: D
Rationale: Rationale: Answer D is correct because testing for GBS at 37 weeks ensures detection of any recent colonization, which can change rapidly. Testing earlier in pregnancy may not accurately reflect GBS status at the time of delivery. Answers A, B, and C are incorrect because the focus should be on current GBS status, not past symptoms or test results. The nurse should prioritize testing closer to delivery for accurate results.
A nurse is administering a hepatitis B vaccine to a newborn. Which of the following actions should the nurse take?
- A. Administer the injection into the vastus lateralis muscle.
- B. Vigorously massage the site following the injection.
- C. Insert the needle at a 45° angle for injection.
- D. Use a 21-gauge needle for the injection.
Correct Answer: A
Rationale: The correct answer is A: Administer the injection into the vastus lateralis muscle. For newborns, the vastus lateralis muscle is the preferred site for intramuscular injections due to its size and well-developed muscle mass, ensuring proper absorption and minimizing the risk of injury to surrounding structures. Administering the vaccine into this muscle also helps improve vaccine efficacy. Choices B, C, and D are incorrect. Choice B, vigorously massaging the site, can cause discomfort, bruising, and potential tissue damage. Choice C, inserting the needle at a 45° angle, is not recommended for intramuscular injections as the needle should be inserted at a 90° angle to ensure proper delivery into the muscle. Choice D, using a 21-gauge needle, is not specific for newborns and can be too large for their small muscle mass, causing unnecessary pain and potential tissue damage.
A nurse is providing discharge teaching to a client following tubal ligation. Which of the following statements by the client indicates an understanding of the teaching?
- A. Premenstrual tension will no longer be present.
- B. My monthly menstrual period will be shorter.
- C. Hormone replacements will be needed following this procedure.
- D. Ovulation will remain the same.
Correct Answer: D
Rationale: The correct answer is D: Ovulation will remain the same. After tubal ligation, the fallopian tubes are blocked to prevent the egg from meeting sperm, but ovulation continues. This answer shows understanding of the procedure's mechanism. A: Premenstrual tension may or may not be affected. B: Menstrual periods are not directly affected. C: Hormone replacements are not routinely needed. In summary, D is correct as it reflects accurate knowledge of tubal ligation outcomes, while the other options are either unrelated or incorrect.
A nurse is preparing to perform Leopold maneuvers on a client who is at 36 weeks of gestation. Identify the sequence of actions the nurse should take.
- A. Instruct the client to empty their bladder.
- B. Position the client supine with knees flexed and place a small, rolled towel under one of their hips.
- C. Palpate the fetal part positioned in the fundus.
- D. Palpate the fetal parts along both sides of the uterus.
Correct Answer: A, B, C, D
Rationale: The correct order for performing Leopold maneuvers on a client at 36 weeks gestation is A, B, C, D. Firstly, instructing the client to empty their bladder (A) allows for better visualization and palpation of the fetus. Secondly, positioning the client supine with knees flexed and placing a small, rolled towel under one hip (B) helps relax the abdominal muscles and provides easier access to the uterus. Next, palpating the fetal part positioned in the fundus (C) helps determine the fetal presentation and position. Finally, palpating the fetal parts along both sides of the uterus (D) allows for further assessment of the fetal position and presentation. Choices E, F, and G are incorrect as they do not align with the sequential steps required for conducting Leopold maneuvers effectively.