A nurse is caring for a client who has an endotracheal tube (ET) and is on mechanical ventilation. Which of the following actions should the nurse take for a ventilator alarm due to an increase in peak airway pressure? (Select all that apply)

Choice A reason: Instructing the client to shower and change clothes is inappropriate, as it may destroy forensic evidence critical for legal proceedings. Evidence preservation is a priority post-sexual assault, and showers are delayed until after forensic examination, making this intervention incorrect and potentially harmful.
Choice B reason: Asking for details about the assault can retraumatize the client and is not the nurse’s role immediately post-assault. Trained forensic examiners or counselors handle such discussions sensitively. This action risks emotional harm and is inappropriate for initial care, making it incorrect.
Choice C reason: Reassuring the client that injuries are not life-threatening may minimize their trauma and emotional distress. The focus should be on emotional support and safety, not downplaying injuries, which may be perceived insensitively. This intervention is inappropriate for trauma-informed care, making it incorrect.
Choice D reason: Limiting staff members providing care reduces the client’s exposure to multiple providers, minimizing retraumatization and ensuring consistency. This trauma-informed approach fosters trust and safety post-sexual assault, aligning with best practices for psychological support, making it the correct intervention.

Choice A reason: Assuring the client about future pregnancies dismisses her current emotional loss, potentially invalidating grief. Stillbirth triggers complex hormonal and psychological responses, including postpartum depression risk. This approach fails to address immediate emotional needs, hindering the grieving process and emotional recovery in perinatal loss.
Choice B reason: Avoiding discussion of the newborn ignores the client’s need to process her loss. Acknowledging the baby’s existence is critical for healthy mourning, as psychological research shows verbalizing grief aids emotional integration. Silence may suppress coping, prolonging unresolved grief and complicating psychological adjustment post-stillbirth.
Choice C reason: Discouraging friends from seeing the newborn dismisses the client’s need for social support. Communal acknowledgment of loss mitigates isolation, a key factor in grief recovery. This action disrupts psychological coping by limiting social validation, potentially exacerbating feelings of loneliness and hindering emotional healing after stillbirth.
Choice D reason: Offering to take pictures acknowledges the baby’s significance, aiding the client’s grieving process. Photographs serve as tangible memories, supported by psychological research as therapeutic in perinatal loss. This intervention fosters emotional closure, validates the loss, and supports healthy mourning, aligning with compassionate care principles.