A nurse is caring for a client immediately following the delivery of a stillborn fetus. Which of the following actions should the nurse take?

Inform the client that the law requires them to name the fetus

Limit the amount of time the fetus is in the client’s room

Instruct the client that an autopsy should be performed within 24 hours

Provide the client with photos of the fetus.

Answer and Explanation

The Correct Answer is D

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.

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Correct Answer is C

Explanation

Choice A rationale
Applying oxygen at 2 L/min via nasal cannula may be beneficial for a client experiencing hypotension following the administration of epidural anesthesia, but it is not the primary action a nurse should take.
Choice B rationale
Massaging the client’s fundus is not an appropriate action for a nurse to take when a client is hypotensive following the administration of epidural anesthesia.
Choice C rationale
Turning the client to a side-lying position is a recommended intervention for hypotension following epidural anesthesia. This position helps improve venous return to the heart and can help alleviate hypotension by reducing aortocaval compression.
Choice D rationale
Assisting the client to empty their bladder may be beneficial in certain circumstances, but it is not the primary action a nurse should take when a client is hypotensive following the administration of epidural anesthesia.

A. “Heart rate 89/min.”. B. “Cool, clammy skin.”. C. “BP 120/70 mm Hg.”. D. “Moderate lochia serosa.”.

Correct Answer is B

Explanation

Choice A rationale
A heart rate of 89/min is within the normal range for an adult, and would not typically be a cause for concern.
Choice B rationale
Cool, clammy skin can be a sign of shock or other serious conditions such as hypoperfusion or inadequate blood flow, which could be a sign of hemorrhage or other circulatory issues. This is a significant finding that should be reported to the provider immediately. Hypoperfusion can lead to inadequate oxygen supply to the body’s organs and tissues, which can result in organ failure and other serious complications. Therefore, any signs of hypoperfusion, including cool, clammy skin, should be reported to the provider immediately for further evaluation and treatment.
Choice C rationale
A blood pressure of 120/70 mm Hg is within the normal range for an adult, and would not typically be a cause for concern.
Choice D rationale
Moderate lochia serosa is a normal finding in a woman who is 3 days postpartum. Lochia serosa is the term for the pink or brownish discharge that occurs after lochia rubra, the bright red discharge that occurs immediately after childbirth. Lochia serosa typically begins about 3- 4 days after delivery and can continue for up to 10 days postpartum.

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A nurse is caring for a client immediately following the delivery of a stillborn fetus. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is hypotensive following the administration of epidural anesthesia. Which action should the nurse take?

Correct Answer is C

Explanation

“A nurse is assessing a patient who is 3 days postpartum. Which of the following findings should the nurse report to the provider?”

Correct Answer is B

Explanation

A nurse is assessing a client who is 1 hour postpartum following a vaginal birth. The nurse notes that the client has excessive vaginal bleeding. What should the nurse do first?

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A nurse is providing discharge teaching to a postpartum client about caring for their newborn at home. Which of the following statements should the nurse make?

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