A community health nurse is working with a family that is struggling to adapt following the loss of a family member. Which of the following actions should the nurse take first?
Encourage the family to assign specific tasks to individual family members.
Assist the family to establish a daily routine.
Refer the family to a grief support group.
Determine the roles of individual family members.
The Correct Answer is D
A. Assigning tasks is important but comes after understanding family dynamics.
B. Establishing a routine is beneficial but should follow assessment.
C. Referring to a support group is valuable but not the immediate first step.
D. Determining family roles helps the nurse assess coping strategies and dynamics, which is essential before planning interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Identify possible precipitating factors related to the infections: The first step in addressing an increase in infections is to determine the underlying causes, which guides appropriate interventions.
B. Revise the current policy for catheter care: Incorrect. Revising policies may be necessary, but it should occur after identifying contributing factors.
C. Meet with providers to discuss measures to decrease the infections: Incorrect. While collaboration is important, it is not the first step.
D. Schedule nursing staff training for infection control procedures: Incorrect. Staff training is essential but should follow identification of the factors contributing to the infections.
Correct Answer is ["A","B","C","E","F"]
Explanation
A. Exert upward pressure on the presenting part. If there are signs of cord prolapse or pressure on the umbilical cord, exerting upward pressure on the presenting part can relieve compression. This action helps maintain blood flow and oxygen supply to the fetus.
B. Place the client in a Trendelenburg position. Positioning the client with the pelvis elevated higher than the head can reduce pressure on the umbilical cord if prolapse is suspected or confirmed. This promotes fetal circulation and decreases the risk of hypoxia.
C. Administer oxygen at 10 L/min via nonrebreather face mask. Administering high-flow oxygen increases maternal oxygenation, which in turn improves oxygen delivery to the fetus. This is a priority intervention to ensure fetal well-being during labor.
D. Attempt to push the umbilical cord back into the cervix. This is incorrect because pushing the cord back into the cervix is contraindicated due to the risk of damaging the cord or introducing infection. Other measures, such as repositioning and elevating the presenting part, should be prioritized instead.
E. Have the charge nurse notify the provider. Timely communication with the provider is critical when complications arise during labor, such as suspected umbilical cord prolapse. The provider may need to intervene urgently, possibly requiring an emergency cesarean section.
F. Increase the flow rate of the maintenance IV fluid. Increasing the IV fluid rate helps improve maternal circulation and blood flow to the uterus and placenta, ensuring the fetus receives adequate oxygen and nutrients. This is a supportive measure during labor when complications arise.
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