A nurse has been monitoring a client who gave birth vaginally 8 hours ago.

Based on the nurse’s notes at 0700 and 1100, select the three findings that necessitate immediate follow-up.

The correct answer is choiceb. Do you notice increased cramping with breastfeeding?

Choice A rationale:Swelling in the feet is not directly related to the need for PRN pain medication following a cesarean birth. Swelling can be a common postpartum symptom due to fluid retention and changes in blood chemistry, but it does not specifically indicate pain that requires medication.

Choice B rationale:Increased cramping with breastfeeding is a common occurrence due to the release of oxytocin, which causes uterine contractions. This can be quite painful and may necessitate PRN pain medication to manage the discomfort.

Choice C rationale:Leakage from the incision could indicate a complication such as infection or wound dehiscence. While this is a serious concern that requires medical attention, it is not directly related to the typical pain management needs following a cesarean birth.

Choice D rationale:The ability to pass gas is an important indicator of the return of bowel function after surgery, but it is not directly related to the need for PRN pain medication. It is more relevant to assessing gastrointestinal recovery rather than pain levels.

Choice A rationale
Informing the client that the law requires them to name the fetus is not accurate. Laws vary by location, but most do not require parents to name a stillborn fetus. It is important to provide accurate information and support the parents in their decisions during this difficult time.
Choice B rationale
Limiting the amount of time the fetus is in the client’s room is not necessarily beneficial. Each family will have different needs and preferences when it comes to spending time with their stillborn baby. Some families may find comfort in holding and spending time with their baby, while others may prefer not to. The nurse should support the family’s decisions and provide compassionate care.
Choice C rationale
Instructing the client that an autopsy should be performed within 24 hours is not necessarily beneficial. The decision to perform an autopsy will depend on a variety of factors, including the parents’ wishes, the circumstances of the stillbirth, and local laws and regulations. It is important to provide the parents with information and support them in making this decision.
Choice D rationale
Providing the client with photos of the fetus can be a helpful part of the grieving process for some families. It allows them to remember their baby and can be a tangible reminder of the baby’s existence. However, this should be done based on the family’s wishes.