A couple, accompanied by their 5-year-old daughter, have been notified that their 32-week-gestation fetus is dead. The father is yelling at the staff. The mother is crying uncontrollably. The 5-year-old is banging the head of her doll on the floor. Which of the following nursing actions is appropriate at this time?

Correct Answer: B

Rationale: In this emotionally charged scenario, the most appropriate nursing action is option B: Sit with the family and quietly communicate sorrow at their loss. This response demonstrates empathy, compassion, and support during a time of deep emotional distress. By sitting with the family and expressing sorrow, the nurse validates their feelings and offers a comforting presence. Option A is incorrect because telling the father his behavior is inappropriate could escalate the situation further and is not the most therapeutic response in this context. Option C is wrong as it lacks empathy and fails to acknowledge that the 5-year-old's behavior is likely a manifestation of her distress and confusion. Option D is also inappropriate as it suggests avoiding the child's presence rather than addressing the family as a unit in need of support. From an educational standpoint, this scenario highlights the importance of therapeutic communication and empathy in nursing practice, especially in sensitive and challenging situations like perinatal loss. Nurses must prioritize emotional support, active listening, and non-judgmental presence to help families navigate through grief and loss effectively.

Correct Answer: B

Rationale: The correct answer is B) INR (international normalized ratio) of 2.5. In the context of a client on Coumadin post-pulmonary embolism after a cesarean delivery, the INR value of 2.5 indicates that the medication is effective in achieving the desired anticoagulant effect. INR is used to monitor the effectiveness of warfarin therapy, with a target range typically between 2.0 to 3.0 for conditions like pulmonary embolism. Option A (PT of 12 sec) is within the normal range, but PT alone is not as specific or sensitive as the INR for monitoring warfarin therapy. Option C (Hematocrit 55%) and D (Hemoglobin 10 g/dL) are not directly related to monitoring the effectiveness of Coumadin therapy in this scenario. Educationally, understanding the significance of monitoring INR in patients on warfarin is crucial for healthcare professionals managing postpartum clients with thromboembolic complications. This knowledge ensures safe and effective anticoagulant therapy to prevent complications like recurrent thromboembolism. Regular monitoring and interpretation of INR values are essential to adjust the dosage of Coumadin for optimal therapeutic outcomes.

Correct Answer: D

Rationale: In this scenario, the most appropriate intervention regarding infant feeding when a breastfeeding woman needs to undergo a hemorrhoidectomy is to have the baby bottle-fed milk that the mother has stored (Option D). This choice is the best because it ensures that the infant continues to receive the benefits of breastmilk while the mother is temporarily unable to breastfeed due to the surgery. Option A, weaning the baby to formula, is not recommended as it can disrupt the established breastfeeding relationship, reduce the mother's milk supply, and deprive the baby of the unique nutrients and antibodies found in breastmilk. Option B, having the baby stay in the hospital room with the mother, may not be feasible during the postoperative period when the mother may not be able to care for the infant adequately due to her recovery needs. Option C, having the woman pump and dump her milk for two weeks, is unnecessary and can lead to a decrease in the mother's milk supply as breastfeeding works on a supply-demand basis. It also unnecessarily deprives the infant of valuable breastmilk. Educationally, this scenario highlights the importance of considering the well-being of both the mother and the infant in situations where breastfeeding may be temporarily interrupted. It emphasizes the need for healthcare providers to support breastfeeding mothers in maintaining their milk supply and providing breastmilk to their infants even during times of medical interventions.

Correct Answer: B

Rationale: The correct answer is B) Avoid overeating dark green, leafy vegetables. Warfarin is an anticoagulant medication that works by inhibiting vitamin K-dependent clotting factors. Dark green, leafy vegetables are high in vitamin K, which can counteract the effects of warfarin, leading to potential fluctuations in the client's international normalized ratio (INR) levels. Therefore, it is crucial for patients on warfarin therapy to maintain consistent levels of vitamin K intake by avoiding sudden increases or decreases in consumption of these foods. Option A) Take only ibuprofen for pain is incorrect because ibuprofen is not typically contraindicated with warfarin therapy. However, it is essential to monitor for bleeding symptoms due to the combined risk of bleeding associated with both medications. Option C) Drink grapefruit juice daily is incorrect as grapefruit juice can interact with various medications, but it does not have a direct impact on warfarin metabolism or efficacy. Option D) Report any decrease in urinary output is not directly related to warfarin therapy post-pulmonary embolism after a cesarean delivery. While monitoring urine output is important for overall health assessment, it is not specifically pertinent to the management of warfarin therapy in this scenario. In an educational context, teaching patients about the dietary considerations while on warfarin therapy is crucial to ensure the medication's effectiveness and reduce the risk of complications. It is essential for healthcare providers to provide comprehensive education to patients to empower them to manage their condition effectively and avoid potential drug interactions or adverse effects.

Correct Answer: C

Rationale: The priority nursing diagnosis for a woman who is PP1 from a spontaneous vaginal delivery with significant postpartum hemorrhage is C) Fluid volume deficit related to blood loss. This is the correct answer because postpartum hemorrhage can lead to a rapid loss of blood volume, potentially resulting in hypovolemic shock and other serious complications. Replenishing the lost fluids is crucial to stabilize the woman's condition and prevent further complications. Option A) Alteration in comfort related to afterbirth pains is important but not the priority in this situation. Pain management is essential, but addressing fluid volume deficit takes precedence due to the potential life-threatening consequences of hemorrhage. Option B) Risk for altered parenting related to grand multiparity is not a priority in the immediate postpartum period. While it is important to support new mothers in their parenting journey, addressing a physiological issue like fluid volume deficit is more urgent. Option D) Risk for sleep deprivation related to mothering role is also not the priority in this scenario. While fatigue and sleep deprivation can impact the new mother's well-being, addressing the physical health issue of fluid volume deficit is more critical for her immediate recovery and safety. In an educational context, understanding the hierarchy of nursing priorities is crucial for providing effective and efficient care. By prioritizing the most critical needs of the patient, nurses can ensure that life-threatening issues are addressed promptly, leading to better patient outcomes. In the case of postpartum hemorrhage, identifying and managing fluid volume deficit is a priority to stabilize the woman's condition and prevent complications.