a nurse is caring for a client following a vaginal delivery of a term fetal demise which of the following statements should the nurse make

HESI LPN

HESI Maternal Newborn

1. A client has experienced a fetal demise following a vaginal delivery at term. What should the nurse advise the client?

A. “You can bathe and dress your baby if you’d like to.”
B. “If you don’t hold the baby, it will make letting go much harder.”
C. “You should name the baby so he/she can have an identity.”
D. “I’m sure you will be able to have another baby when you’re ready.”

Correct answer: A

Rationale: After a fetal demise, allowing the parents to bathe and dress their baby can offer them a sense of closure and help them in their grieving process. This act can provide a tangible way for the parents to bond with their baby and create lasting memories. Option B is incorrect because each individual may have different emotional needs and holding the baby may not be appropriate or helpful for everyone. Option C, while well-intentioned, may not be suitable for all parents as naming the baby could be emotionally challenging. Option D is insensitive as it overlooks the grieving process of losing a baby by suggesting a replacement.

2. Females with Turner syndrome:

A. possess more thymine than cytosine.
B. are taller than average.
C. produce little estrogen.
D. are more likely to give birth to twins.

Correct answer: C

Rationale: Turner syndrome is a chromosomal disorder in females characterized by short stature and underdeveloped ovaries, resulting in low estrogen production. This leads to symptoms such as delayed puberty and infertility. Choice A is incorrect because the chromosomal abnormality in Turner syndrome does not affect the thymine-cytosine ratio. Choice B is incorrect as females with Turner syndrome are typically shorter than average. Choice D is incorrect as Turner syndrome does not increase the likelihood of giving birth to twins.

3. A client in the transition phase of labor reports a pain level of 7 on a scale of 0 to 10. Which of the following actions should the nurse take?

A. Instruct the client to use effleurage.
B. Apply counterpressure to the client's sacrum.
C. Assist the client with patterned-paced breathing.
D. Teach the client the technique of biofeedback.

Correct answer: B

Rationale: During the transition phase of labor, a client may experience intense back pain due to the pressure of the baby descending. Applying counterpressure to the client's sacrum can help alleviate this discomfort. Effleurage is a light stroking massage technique that may not provide adequate relief for intense back pain. Patterned-paced breathing is beneficial for managing contractions but may not directly address back pain. Biofeedback is a technique that helps individuals gain awareness and control of certain physiological functions, but it may not be the most appropriate intervention for acute labor pain.

4. A client at 27 weeks of gestation with preeclampsia is being assessed by a nurse. Which of the following findings should the nurse report to the provider?

A. Urine protein concentration of 200 mg/24 hr.
B. Creatinine level of 0.8 mg/dL
C. Hemoglobin level of 14.8 g/dL
D. Platelet count of 60,000/mm3

Correct answer: D

Rationale: A platelet count of 60,000/mm3 is significantly low and can indicate HELLP syndrome, a severe complication of preeclampsia that involves hemolysis, elevated liver enzymes, and low platelet count. HELLP syndrome requires prompt medical intervention to prevent serious maternal and fetal complications. The other findings listed are within normal limits or not directly related to the severe condition associated with HELLP syndrome.

5. Which of the following statements is true about Tay-Sachs disease?

A. It is most commonly found among children in Jewish families of Eastern European background.
B. Children who have this disease suffer from excessive production of mucus in the lungs and pancreas.
C. It is most commonly found among children in Asian American families.
D. Children who have this disease suffer from muscular dystrophy characterized by a weakening of the muscles.

Correct answer: A

Rationale: The correct answer is A. Tay-Sachs disease is most commonly found among Jewish families of Eastern European descent. It is a fatal genetic disorder that affects the nervous system. Choice B is incorrect because Tay-Sachs disease does not involve excessive mucus production in the lungs and pancreas. Choice C is incorrect as it states that Tay-Sachs disease is most commonly found among Asian American families, which is inaccurate. Choice D is also incorrect because Tay-Sachs disease does not cause muscular dystrophy characterized by weakening of the muscles.