,1. A Primipara Has Delivered a Stillborn Fetus at 30 Weeks' Gestation
A primiparous client delivers a stillborn fetus at 30 weeks' gestation after a pregnancy
complicated by placental insufficiency. The parents are visibly devastated, crying, and
expressing disbelief over the loss. They ask the nurse if they can see their baby but
also state that they are unsure what they should do next. The nurse recognizes that
providing compassionate bereavement care is essential to support healthy grieving.
Correct Answer: Provide a private opportunity for the parents to hold their infant.
Rationale: Allowing parents to see and hold their stillborn infant provides an
important opportunity to acknowledge the baby's existence and begin the grieving
process. Creating memories through holding, touching, or spending private time with
the infant has been shown to promote healthy emotional adjustment and reduce the
likelihood of complicated grief. The nurse should respect the parents' wishes while
offering gentle encouragement and emotional support throughout the experience.
2. A Primipara Has Delivered a Stillborn Fetus at 30 Weeks' Gestation. To Assess the
Parents in the Grieving Process, Which Intervention Is Most Important for the
Nurse to Implement?
A primiparous client has delivered a stillborn fetus at 30 weeks' gestation. The
parents remain in the delivery room quietly crying and have asked several questions
about why this happened. The nurse understands that interventions promoting
healthy grieving should be initiated immediately after delivery while respecting the
family's individual preferences.
Correct Answer: Provide a private opportunity for the parents to hold their infant.
Rationale: Holding the infant allows parents to establish memories, acknowledge
their baby's life, and begin processing their loss in a meaningful way. Privacy
promotes open emotional expression without interruption and supports
individualized grieving. This intervention is recognized as one of the most therapeutic
nursing actions following fetal loss.
,3. What Is the Priority Nursing Assessment Immediately Following the Birth of an
Infant With Esophageal Atresia and a Tracheoesophageal Fistula?
A newborn is delivered at term and is suspected of having esophageal atresia with a
tracheoesophageal fistula after excessive oral secretions, choking, and coughing are
noted during the initial assessment. The infant has not yet been fed, and the
healthcare provider is preparing for further diagnostic evaluation. The nurse begins
the priority assessment while preventing further complications.
Correct Answer: Body temperature.
Rationale: Newborns with congenital anomalies are highly susceptible to heat loss
because of their immature thermoregulatory mechanisms. Maintaining normal body
temperature reduces oxygen consumption, metabolic stress, and additional
physiologic instability while preparations are made for definitive treatment.
Preventing hypothermia supports overall cardiorespiratory stability and decreases
the risk of neonatal complications.
4. What Is the Most Important Assessment for the Nurse to Conduct Following the
Administration of Epidural Anesthesia to a Client Who Is at 40 Weeks' Gestation?
A client at 40 weeks' gestation receives epidural anesthesia for labor pain
management. Within several minutes after the medication is administered, the nurse
begins frequent maternal and fetal assessments to identify any complications
associated with the regional anesthetic.
Correct Answer: Maternal blood pressure.
Rationale: Epidural anesthesia commonly causes peripheral vasodilation, which
can lead to maternal hypotension. Significant decreases in maternal blood pressure
reduce uteroplacental blood flow, placing the fetus at risk for hypoxia and fetal
distress. Early identification and treatment of hypotension help maintain adequate
maternal circulation and fetal oxygenation.
, 5. A 34-Week Primigravida With Preeclampsia Is Receiving Lactated Ringer's 500 mL
With Magnesium Sulfate 20 Grams at a Rate of 3 Grams per Hour. How Many mL
per Hour Should the Nurse Program Into the Infusion Pump?
A 34-week primigravid client with severe preeclampsia is admitted for seizure
prophylaxis. The healthcare provider prescribes magnesium sulfate 20 grams diluted
in 500 mL of Lactated Ringer's solution to infuse at 3 grams per hour. The nurse
calculates the hourly infusion rate before programming the infusion pump.
Correct Answer: 75 mL/hour.
Rationale: The solution contains 20 grams of magnesium sulfate in 500 mL,
resulting in a concentration of 0.04 grams/mL. To administer 3 grams each hour, the
nurse divides 3 grams by 0.04 grams/mL, resulting in an infusion rate of 75 mL/hour.
Accurate dosage calculation is essential because magnesium sulfate has a narrow
therapeutic range, and incorrect infusion rates can result in maternal toxicity or
inadequate seizure prevention.
6. A 6-Year-Old With Heart Failure Has Gained 2 Pounds During the Last 24 Hours.
Which Intervention Is Most Important for the Nurse to Implement?
A 6-year-old child with a history of chronic heart failure is admitted for monitoring.
During the morning assessment, the nurse notes that the child's weight has increased
by 2 pounds over the previous 24 hours. The child appears mildly fatigued but denies
pain.
Correct Answer: Assess bilateral lung sounds.
Rationale: A rapid weight gain in a child with heart failure strongly suggests fluid
retention and possible worsening pulmonary congestion. Auscultating lung sounds
helps detect crackles or diminished breath sounds that indicate pulmonary edema
requiring prompt intervention. Early recognition of fluid overload allows timely
treatment and helps prevent respiratory compromise.
A primiparous client delivers a stillborn fetus at 30 weeks' gestation after a pregnancy
complicated by placental insufficiency. The parents are visibly devastated, crying, and
expressing disbelief over the loss. They ask the nurse if they can see their baby but
also state that they are unsure what they should do next. The nurse recognizes that
providing compassionate bereavement care is essential to support healthy grieving.
Correct Answer: Provide a private opportunity for the parents to hold their infant.
Rationale: Allowing parents to see and hold their stillborn infant provides an
important opportunity to acknowledge the baby's existence and begin the grieving
process. Creating memories through holding, touching, or spending private time with
the infant has been shown to promote healthy emotional adjustment and reduce the
likelihood of complicated grief. The nurse should respect the parents' wishes while
offering gentle encouragement and emotional support throughout the experience.
2. A Primipara Has Delivered a Stillborn Fetus at 30 Weeks' Gestation. To Assess the
Parents in the Grieving Process, Which Intervention Is Most Important for the
Nurse to Implement?
A primiparous client has delivered a stillborn fetus at 30 weeks' gestation. The
parents remain in the delivery room quietly crying and have asked several questions
about why this happened. The nurse understands that interventions promoting
healthy grieving should be initiated immediately after delivery while respecting the
family's individual preferences.
Correct Answer: Provide a private opportunity for the parents to hold their infant.
Rationale: Holding the infant allows parents to establish memories, acknowledge
their baby's life, and begin processing their loss in a meaningful way. Privacy
promotes open emotional expression without interruption and supports
individualized grieving. This intervention is recognized as one of the most therapeutic
nursing actions following fetal loss.
,3. What Is the Priority Nursing Assessment Immediately Following the Birth of an
Infant With Esophageal Atresia and a Tracheoesophageal Fistula?
A newborn is delivered at term and is suspected of having esophageal atresia with a
tracheoesophageal fistula after excessive oral secretions, choking, and coughing are
noted during the initial assessment. The infant has not yet been fed, and the
healthcare provider is preparing for further diagnostic evaluation. The nurse begins
the priority assessment while preventing further complications.
Correct Answer: Body temperature.
Rationale: Newborns with congenital anomalies are highly susceptible to heat loss
because of their immature thermoregulatory mechanisms. Maintaining normal body
temperature reduces oxygen consumption, metabolic stress, and additional
physiologic instability while preparations are made for definitive treatment.
Preventing hypothermia supports overall cardiorespiratory stability and decreases
the risk of neonatal complications.
4. What Is the Most Important Assessment for the Nurse to Conduct Following the
Administration of Epidural Anesthesia to a Client Who Is at 40 Weeks' Gestation?
A client at 40 weeks' gestation receives epidural anesthesia for labor pain
management. Within several minutes after the medication is administered, the nurse
begins frequent maternal and fetal assessments to identify any complications
associated with the regional anesthetic.
Correct Answer: Maternal blood pressure.
Rationale: Epidural anesthesia commonly causes peripheral vasodilation, which
can lead to maternal hypotension. Significant decreases in maternal blood pressure
reduce uteroplacental blood flow, placing the fetus at risk for hypoxia and fetal
distress. Early identification and treatment of hypotension help maintain adequate
maternal circulation and fetal oxygenation.
, 5. A 34-Week Primigravida With Preeclampsia Is Receiving Lactated Ringer's 500 mL
With Magnesium Sulfate 20 Grams at a Rate of 3 Grams per Hour. How Many mL
per Hour Should the Nurse Program Into the Infusion Pump?
A 34-week primigravid client with severe preeclampsia is admitted for seizure
prophylaxis. The healthcare provider prescribes magnesium sulfate 20 grams diluted
in 500 mL of Lactated Ringer's solution to infuse at 3 grams per hour. The nurse
calculates the hourly infusion rate before programming the infusion pump.
Correct Answer: 75 mL/hour.
Rationale: The solution contains 20 grams of magnesium sulfate in 500 mL,
resulting in a concentration of 0.04 grams/mL. To administer 3 grams each hour, the
nurse divides 3 grams by 0.04 grams/mL, resulting in an infusion rate of 75 mL/hour.
Accurate dosage calculation is essential because magnesium sulfate has a narrow
therapeutic range, and incorrect infusion rates can result in maternal toxicity or
inadequate seizure prevention.
6. A 6-Year-Old With Heart Failure Has Gained 2 Pounds During the Last 24 Hours.
Which Intervention Is Most Important for the Nurse to Implement?
A 6-year-old child with a history of chronic heart failure is admitted for monitoring.
During the morning assessment, the nurse notes that the child's weight has increased
by 2 pounds over the previous 24 hours. The child appears mildly fatigued but denies
pain.
Correct Answer: Assess bilateral lung sounds.
Rationale: A rapid weight gain in a child with heart failure strongly suggests fluid
retention and possible worsening pulmonary congestion. Auscultating lung sounds
helps detect crackles or diminished breath sounds that indicate pulmonary edema
requiring prompt intervention. Early recognition of fluid overload allows timely
treatment and helps prevent respiratory compromise.
