A nurse is caring for a client who just delivered a stillborn infant at 36 weeks gestation.Which of the following responses should the nurse make?
I understand your grief.I lost a baby also.
I have called for the chaplain to come and stay with you.
You may hold your baby as long as you want.
This is for the best.Your baby was very ill.
The Correct Answer is C
Choice A rationale
While sharing personal experiences can sometimes be comforting, it may not always be appropriate or helpful in a professional setting. The focus should be on the patient’s needs and feelings.
Choice B rationale
Calling for a chaplain can be supportive, but it is important to first offer the parents the opportunity to hold their baby and spend time with them, which can be an important part of the grieving process.
Choice C rationale
Allowing the parents to hold their baby for as long as they want provides them with the opportunity to say goodbye and can be a crucial part of the grieving process. It helps them to acknowledge their loss and begin to process their emotions.
Choice D rationale
Telling the parents that the loss is for the best is not supportive and can be hurtful. It is important to validate their feelings and provide compassionate care during this difficult time.
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Correct Answer is B
Explanation
Choice A rationale
Fungal infections typically present with itching, redness, and a thick, white discharge resembling cottage cheese. The yellow-white vaginal drainage described is more consistent with lochia alba, the final stage of lochia, which is a normal postpartum discharge.
Choice B rationale
Lochia alba is the final stage of lochia, occurring around 10 to 14 days postpartum and lasting up to six weeks. It is characterized by a yellowish-white discharge, indicating the end of the postpartum bleeding process.
Choice C rationale
Retained placenta can cause prolonged bleeding and infection, but it is usually associated with heavy bleeding and not a yellow-white discharge. The presence of lochia alba suggests normal postpartum progression.
Choice D rationale
Bacterial infections often present with a foul-smelling discharge, pain, and fever. The yellow-white discharge described is more indicative of lochia alba, a normal postpartum occurrence.
Correct Answer is B
Explanation
Choice A rationale
Massaging the area is not recommended as it can dislodge a clot and cause it to travel to the lungs, leading to a pulmonary embolism. This can be life-threatening and should be avoided.
Choice B rationale
Elevating the leg helps to reduce swelling and pain by promoting venous return. This is a standard intervention for managing symptoms of deep vein thrombosis (DVT) and helps prevent further complications.
Choice C rationale
Applying cold compresses is not effective for DVT. Cold compresses are generally used to reduce inflammation and pain in acute injuries, but they do not address the underlying issue of a blood clot.
Choice D rationale
Flexing the knee while resting can increase the risk of clot dislodgement and is not recommended. Keeping the leg straight and elevated is a safer approach to managing DVT symptoms.