A nurse is caring for a couple who experienced a fetal death at 37 weeks of gestation. Which of the following responses by the nurse is therapeutic?
"I think you should call your minister. He can help comfort you."
"It must be very difficult for you both. I will be available if you need anything."
"You are both young and can have other children."
"Did you have any complications during your pregnancy?"
The Correct Answer is B
Choice A rationale: This response assumes that the couple's religious beliefs are relevant to them, which may not be the case. It is not appropriate for the nurse to suggest involving their minister without knowing their preferences or beliefs.
Choice B rationale: This response acknowledges the couple's emotional experience and shows empathy toward their grief. It offers support and reassurance that the nurse will be available to help them through this difficult time.
Choice C rationale: While this statement may be factually true, it is not empathetic or supportive of the couple's current emotional state. It may come across as dismissive of their feelings and minimize their grief.
Choice D rationale: While gathering information about the pregnancy is essential for the medical record, this question does not address the couple's emotional needs. It is more appropriate to focus on offering emotional support and assistance rather than immediately delving into clinical details.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale; Erythema toxicum is a common rash that appears in many newborns and is not a cause for concern. It presents as small red bumps or pustules on the skin and usually resolves on its own without treatment.
Choice B rationale: A Mongolian spot is a birthmark that appears as a bluish-gray or bruise-like patch on the baby's skin, often on the back or buttocks. It is a benign condition and does not require any medical intervention.
Choice C rationale: Telangiectatic nevi, also known as "stork bites" or "angel kisses," are flat, pink, or red birthmarks that are common in newborns. They are usually found on the eyelids, forehead, and back of the neck. These birthmarks are harmless and typically fade over time without treatment.
Choice D rationale: Jaundice is a common condition in newborns and is caused by elevated levels of bilirubin in the blood. In most cases, mild jaundice is not harmful and resolves on its own. However, if the baby's skin and sclera (white part of the eyes) show significant yellowing, it may indicate a higher level of bilirubin, which can lead to complications if not properly managed. Therefore, the nurse should report this finding to the provider for further evaluation and appropriate treatment if necessary.
Correct Answer is B
Explanation
Choice A rationale: The Mongolian spot is a bluish-gray birthmark that is often seen on the lower back or buttocks of newborns with darker skin tones. It is not related to the swelling described in the scenario.
Choice B rationale: Caput succedaneum is a common condition in newborns delivered by vacuum extraction. It is characterized by swelling of the soft tissues of the scalp that crosses the suture lines. The swelling occurs due to pressure from the vacuum extractor during delivery and is caused by fluid accumulation between the scalp and the skull. Caput succedaneum is typically a benign and self-resolving condition that does not require treatment.
Choice C rationale: Cephalhematoma is a collection of blood between the periosteum and the skull bone. Unlike caput succedaneum, it does not cross the suture lines and can take weeks to months to resolve.
Choice D rationale: Erythema toxicum is a common skin rash in newborns characterized by red or pink spots with a yellow or white bump in the center. It is not related to the swelling described in the scenario.

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