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 D

Explanation

The correct answer is choice d. Administering broad-spectrum antibiotics.

Choice A rationale:

Cleansing the site with povidone-iodine is not recommended because it can be irritating and potentially harmful to the exposed neural tissue.

Choice B rationale:

Monitoring the rectal temperature every 4 hours is not appropriate as it can increase the risk of infection and trauma to the site. Axillary temperature monitoring is preferred.

Choice C rationale:

Preparing for surgical closure after 72 hours is incorrect. Surgical closure is typically performed within the first 24 to 48 hours to prevent infection and further damage to the neural tissue.

Choice D rationale:

Administering broad-spectrum antibiotics is crucial to prevent infection, especially since the cerebrospinal fluid is leaking, which increases the risk of meningitis and other infections.

A. “There was no indication of GBS in your earlier prenatal testing.”. B. “Your previous deliveries were all negative for GBS.”. C. “You didn’t report any symptoms of GBS during your pregnancy.”. D. “GBS testing is typically done between 35-37 weeks of gestation.”. .

Correct Answer is D

Explanation

Choice A rationale
While it’s true that there may not have been any indication of GBS in earlier prenatal testing, this does not explain why the test was not conducted earlier. GBS can come and go in the body, so a negative test earlier in pregnancy does not guarantee that the woman will still be GBS-negative later in pregnancy.
Choice B rationale
Even if previous deliveries were all negative for GBS, this does not mean that the woman will not have GBS in this pregnancy. GBS can come and go in the body, so each pregnancy is considered separately.
Choice C rationale
GBS is usually asymptomatic in adults, so the woman would not typically report any symptoms of GBS during her pregnancy. This does not explain why the test was not conducted earlier.
Choice D rationale
GBS testing is typically done between 35-37 weeks of gestation. This is because GBS can come and go in the body, so testing during this time frame gives the best prediction of whether or not the woman will have GBS at the time of delivery.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Correct Answer is D

Explanation

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