A nurse in an emergency department is caring for a child who reports being sexually abused by a family member.

Which of the following actions should the nurse take?

Choice A reason:

Offer to take pictures of the newborn for the client is the right choice, During the initial grieving process after experiencing a stillbirth, the nurse should offer to take pictures of the newborn for the client if the client wishes. Offering to take pictures is an essential and sensitive way to honour and validate the client's experience and the significance of their baby. It allows the client to have tangible memories of their child, which can be important for the grieving process and help in the healing journey.

It is crucial for the nurse to be supportive and compassionate during this time, respecting the client's emotional needs and preferences. Providing emotional support and empathy are critical components of caring for a client who has experienced the loss of a baby.

Choice B reason:

Assure the client that she can have additional children is not correct. While this statement may be well-intentioned, it may not be appropriate during the initial grieving process. The client may not be emotionally ready to discuss future pregnancies, and such assurances might minimize the significance of the loss they are experiencing. It is essential to be sensitive and refrain from making assumptions about the client's feelings or future plans.

Choice C reason:

Avoid talking to the client about the newborn. Avoiding talking to the client about the newborn may be seen as disregarding their feelings and emotions. Instead, it is essential to provide opportunities for the client to talk about their feelings and the baby if they wish to do so. Creating an environment where the client feels comfortable expressing their emotions can be crucial in the grieving process.

Choice D reason

Discouraging the client from allowing friends to see the newborn It is not appropriate for the nurse to discourage or prevent the client from allowing friends to see the newborn if they wish to do so. Grieving is a highly individual process, and some clients may find comfort and support in sharing their grief with loved ones. The nurse should respect the client's decisions regarding who they want to involve in their grieving process.

Choice A reason:

Completing an incident report is not the correct action. An incident report should be completed as part of the hospital's protocol to document the medication error and ensure appropriate follow-up and investigation.

Choice B reason:

Checking the client for indications of bleeding is the correct action to be taken. In this situation, the nurse's first priority should be to assess the client for indications of bleeding, as the client received a significantly higher dose of IV heparin than prescribed. Heparin is an anticoagulant medication used to prevent blood clots, and an overdose can increase the risk of bleeding.

After administering the wrong dose of medication, the nurse's immediate concern is the client's safety and well-being. Checking for signs of bleeding, such as petechiae, ecchymosis, hematomas, bleeding gums, melena (black, tarry stools), haematuria (blood in urine), or any other unusual bleeding, is crucial.

Choice C reason:

Monitor the client's aPTT levels: This is not the correct action to be taken. Monitoring the client's activated partial thromboplastin time (aPTT) levels is essential to assess the client's coagulation status and determine if the overdose of heparin has affected their clotting ability. The healthcare provider may adjust the heparin dosage based on the aPTT levels.

Choice D reason:

Notify the risk manager: This is not the correct action to be taken. The risk manager or appropriate supervisor should be informed about the medication error as soon as possible to initiate a thorough review of the incident and take necessary steps to prevent similar errors in the future.