The nurse is caring for a client whose fetus died in utero at 32-weeks gestation. After the fetus is delivered vaginally, the nurse implements routine fetal demise protocol and identification procedures Which action is most important for the nurse to take?
Explain reasons consent for an infant autopsy is needed
Determine if the mother desires a visit from her clergy
Encourage the mother to hold and spend time with her baby
Create a memory box of baby's footprints and photographs
The Correct Answer is C
Explain reasons consent for an infant autopsy is needed:
Autopsy might be necessary for understanding the cause of fetal demise, providing answers to the parents, and helping future pregnancies. However, it's not the most immediate or essential action in this scenario.
Determine if the mother desires a visit from her clergy:
Spiritual and emotional support is crucial during this distressing time. While clergy support is valuable, it's not the most urgent action needed immediately after delivery.
Encourage the mother to hold and spend time with her baby:
This is a crucial part of the grieving process and helps in acknowledging and creating memories with the baby. It's an essential step in providing emotional support to the mother.
Create a memory box of baby's footprints and photographs:
This is also a critical step in assisting the parents with the grieving process. It helps in cherishing the memories and creating keepsakes that may provide comfort in the future.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Hemoglobin A1C: Hemoglobin A1C is a test that reflects the average blood sugar levels over the past two to three months. It is not typically used for diagnosing gestational diabetes.
B. Postprandial blood glucose test: This test measures blood sugar levels after meals. While it can provide information about how the body processes glucose after eating, it's not the primary test for diagnosing gestational diabetes.
C. Fasting blood glucose: This test measures blood sugar levels after a period of fasting. It is a standard test used to diagnose gestational diabetes.
D. Oral glucose tolerance test (OGTT): This test involves fasting overnight and then drinking a glucose solution. Blood sugar levels are tested at intervals afterward. The OGTT is a common diagnostic test for gestational diabetes.
Correct Answer is C
Explanation
A. Assign a practical nurse (PN) to reassess the client's vital signs:
While reassessing vital signs is important, the reported severe headache after delivery is a symptom that requires immediate attention. It's more appropriate for a licensed professional, such as the nurse or healthcare provider, to assess and decide the course of action.
B. Obtain a STAT hemoglobin and hematocrit:
While assessing hemoglobin and hematocrit can provide information about potential postpartum hemorrhage, it may not be the first action needed in this context. The severe headache suggests a possible neurological concern that should be addressed promptly.
C. Notify the healthcare provider of the assessment findings:
This is the most appropriate initial action. Severe headache after delivery, especially if the client had received anesthesia, could be indicative of post-dural puncture headache (PDPH). Prompt notification allows the healthcare provider to assess and decide on the necessary interventions.
D. Determine if the client received anesthesia during delivery:
Knowing the type of anesthesia is important for understanding potential complications. However, this information alone might not guide immediate actions. The focus should be on addressing the reported severe headache promptly.
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