A nurse is assessing a client who is in active labor.

Which of the following findings should the nurse report to the provider?

The correct answer is choice C. Perform the procedure prior to meals.

This is because postural drainage involves positioning the child in different ways to help drain the mucus from the lungs.

If the child has a full stomach, this can cause nausea, vomiting, or aspiration. Therefore, the nurse should perform the procedure before meals or at least 1 hour after meals.

Choice A is wrong because the nurse should not hold the hand flat to perform percussions on the child.

Percussions are rhythmic clapping on the chest wall to loosen the mucus. The nurse should use a cupped hand to create a small air pocket that enhances the vibrations and prevents bruising.

Choice B is wrong because the nurse should not perform the procedure twice a day. The recommended frequency of postural drainage is 3 to 4 times a day, or more if needed, depending on the child’s condition and tolerance.

Choice D is wrong because the nurse should not administer a bronchodilator after the procedure.

A bronchodilator is a medication that relaxes and widens the airways, making it easier to breathe. The nurse should administer a bronchodilator before the procedure to enhance the effectiveness of postural drainage.

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.