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

Explanation

Choice A Reason:

"Limit visitors to your immediate family." This response is inappropriate. While limiting visitors to immediate family members can help control access to the newborn, it may not fully address security concerns. Some hospitals have specific visitor policies in place, but this instruction alone may not cover all aspects of newborn security.

Choice B Reason:

"Send the newborn to the nursery while you are sleeping." This statement is inappropriate. Sending the newborn to the nursery while the parents are sleeping may seem like a security measure, but it can actually increase the risk of infant abduction or mix-ups. Rooming-in with the newborn allows the parents to maintain constant supervision and bonding with their baby, which is important for security.

Choice C Reason:

"Remove your newborn's electronic monitoring band for bathing." This statement is inappropriate. Removing the electronic monitoring band for bathing can disrupt the tracking system used to ensure the newborn's security within the hospital. It's important to keep the monitoring band on the newborn at all times to accurately track their location and prevent unauthorized removal from the maternity unit.

Choice D Reason:

"Check identification badges of staff who enter your room." This statement is appropriate. Maintaining newborn security is crucial in a hospital setting to ensure the safety of the newborn. Checking identification badges of staff who enter the room helps verify that only authorized personnel are interacting with the newborn and reduces the risk of unauthorized individuals gaining access to the baby.

A. Escort the client to the bathroom:The first step is to encourage spontaneous voiding. Escorting the client to the bathroom is the least invasive intervention and allows the client the opportunity to empty their bladder naturally. It is always preferable to encourage spontaneous voiding before attempting other methods.

B. Offer the client a sitz bath: While a sitz bath can help relax the perineal muscles and relieve discomfort, it is not the first-line intervention for bladder distention. The primary goal is to encourage voiding, and more direct interventions (e.g., escorting the client to the bathroom) should be attempted first.

C. Pour warm water over the client's perineum: Pouring warm water over the perineum may help stimulate voiding by triggering the micturition reflex, but it should be attempted after the client has tried to void naturally. While helpful, it’s not the first step, as it is less practical than simply escorting the client to the bathroom.

D. Insert a urinary catheter:Inserting a urinary catheter is the most invasive option and should only be used as a last resort if less invasive methods fail to relieve bladder distention. Catheterization carries risks such as infection, so it is only done if other measures to stimulate voiding are unsuccessful.