A nurse in the emergency department is caring for a 19-year-old patient who is at 18 weeks of gestation.

The patient presents with reports of nausea and vomiting for the past several weeks, which has worsened in severity. The patient states that they have been unable to retain even clear fluids for the past 48 hours.

The patient reports no pain.

The patient reports a history of migraines and asthma.

What condition is the patient most likely experiencing? What are two actions the nurse should take to address that condition, and what are two parameters the nurse should monitor to assess the patient’s progress?

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.

Choice A rationale
Providing a stimulating environment is not recommended for infants with neonatal abstinence syndrome (NAS). These infants often have a heightened response to stimuli, and a calm, quiet environment is usually more beneficial.
Choice B rationale
While it is important to monitor the infant’s overall health, there is no specific need to monitor blood glucose level every hour in infants with NAS unless there is a separate medical indication.
Choice C rationale
Initiating seizure precautions is an appropriate action for a nurse caring for an infant with signs of NAS5. Infants with NAS are at risk for seizures, so nurses should be prepared to manage this potential complication.
Choice D rationale
Placing the infant on his back with legs extended is not recommended. Infants with NAS often have increased muscle tone and may be uncomfortable in this position.