A nurse is caring for a client following a vaginal delivery of a term fetal demise. What statements should the nurse make?
“If you don’t hold the baby, it will make letting go much harder.”.
“I’m sure you will be able to have another baby when you’re ready.”.
“You can bathe and dress your baby if you’d like to.”.
“You should name the baby so she can have an identity.”.
The Correct Answer is C
Choice A rationale
Telling a grieving mother that not holding her baby will make letting go much harder can be seen as insensitive and may not be true for all individuals. Each person’s grief process is unique.
Choice B rationale
Assuring the mother that she will be able to have another baby when she’s ready may be seen as dismissive of her current loss. It’s important to acknowledge the pain of losing this specific child, rather than focusing on future children.
Choice C rationale
This is the correct answer. Offering the mother the opportunity to bathe and dress her baby can provide a sense of closure and a chance to say goodbye. It allows the mother to care for her baby in the short time they have together.
Choice D rationale
While some parents may find comfort in naming their baby, it should not be presented as something the mother “should” do. The decision to name the baby is a personal one and should be left up to the parents.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
An absent Moro reflex is not typically associated with neonatal abstinence syndrome (NAS), a condition that can occur in newborns exposed to opioids in utero.
Choice B rationale
A weak cry is a common symptom of NAS. Newborns with this syndrome often have high- pitched or weak cries.
Choice C rationale
Poor feeding is a symptom of NAS, but it is not the most specific symptom in this context.
Choice D rationale
A respiratory rate of 30/min is within the normal range for a newborn and is not indicative of NAS5.
Correct Answer is D
Explanation
Choice A rationale
The report of perineal pain as 0 on a scale of 0 to 10 is not directly related to the effectiveness of the IV bolus of lactated Ringer’s. Perineal pain is more associated with the birthing process and not with the administration of IV fluids.
Choice B rationale
Relief of pruritus is not a direct indication of the effectiveness of the IV bolus of lactated Ringer’s. Pruritus, or itching, can be a side effect of certain medications or a symptom of various conditions, but it is not typically associated with the administration of IV fluids.
Choice C rationale
While increased urinary output can be a sign of adequate hydration, it is not the primary indicator of the effectiveness of a bolus of lactated Ringer’s. Urinary output can be influenced by various factors, including kidney function and fluid intake, but a single instance of increased urinary output does not necessarily indicate that the IV bolus was effective.
Choice D rationale
The primary goal of administering a bolus of IV fluids like lactated Ringer’s in a client who is in labor and has a prescription for spinal anesthesia is to maintain or improve the client’s hemodynamic status, which includes maintaining a stable blood pressure. Therefore, a blood pressure reading of 110/70 mm Hg indicates that the IV bolus was effective.
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