A nurse is caring for a client immediately following the delivery of a stillborn fetus. Which of the following actions should the nurse take?
Instruct the client that an autopsy should be performed within 24 hr.
Inform the client that the law requires them to name the fetus.
Provide the client with photos of the fetus.
Limit the amount of time the fetus is in the client's room.
The Correct Answer is C
Rationale:
A. Instructing the client about an autopsy is not the immediate priority and may not be appropriate at this sensitive time.
B. Informing the client about the law regarding naming the fetus is not a priority and may add unnecessary stress to the situation.
C. Providing photos of the fetus is the most appropriate action since it minimzes the trauma to the mother while providing closures.
D. Limiting the amount of time the fetus is in the client's room is not appropriate as when the mother needs more time with the fetus, she hsould be allowed to provide for closure
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Related Questions
Correct Answer is A
Explanation
A.
Rationale:
A. Massaging the client's fundus is the priority action to address excessive vaginal bleeding.
Massaging the fundus helps promote uterine contractions, which can help control bleeding by compressing blood vessels.
B. Emptying the client's bladder may be necessary to relieve pressure on the uterus, but it is not the first priority when addressing excessive bleeding.
C. Providing oxygen may be indicated if the client shows signs of hypoxia, but it is not the first action to address excessive vaginal bleeding.
D. Administering oxytocin may be necessary to help control bleeding, but massaging the fundus is the first step in managing postpartum hemorrhage.
Correct Answer is C
Explanation
Rationale:
A. Applying an ice pack to the incision site is not indicated for addressing vaginal bleeding after cesarean birth and may not effectively address the underlying cause.
B. Replacing the surgical dressing is not the first action to take when assessing vaginal bleeding after cesarean birth. The priority is to evaluate the client's condition and identify the cause of the bleeding.
C. Evaluating urinary output is important to assess for urinary retention, which can contribute to uterine atony and postpartum bleeding. A full bladder can interfere with uterine contraction and lead to increased bleeding.
D. Administering a lactated Ringer's IV bolus may be indicated if the client is hypovolemic due to excessive bleeding, but it is not the first action to take. Assessing urinary output and addressing potential causes of bleeding take precedence.
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