A primipara has delivered a stillborn fetus at 30 weeks gestation. To assist the parents in the grieving process, which intervention is most important for the nurse to implement?

Correct Answer: A

Rationale: The most important intervention for the nurse to implement in this situation is option A, which is to provide an opportunity for the parents to hold their infant in privacy. This intervention is crucial as it allows the parents to create memories with their stillborn baby, fostering a sense of connection and closure. It also validates the reality of their loss, enabling them to begin the grieving process and start the healing journey. Option B, assisting the couple in completing a request for autopsy, may not be the most important intervention at this moment. While obtaining information about the cause of fetal demise can be valuable for closure and future family planning, the immediate emotional needs of the parents should take precedence. Option C, encouraging the couple to seek family counseling within the next few weeks, is also important for long-term support. However, in the immediate aftermath of the stillbirth, providing emotional support and facilitating the grieving process should be the primary focus. Option D, explaining the possible causes of fetal demise, is not the most appropriate intervention at this time. The parents may not be ready to process detailed medical information while they are grieving the loss of their baby. Prioritizing emotional support and allowing them to process their feelings should come first before discussing medical specifics.

Correct Answer: B

Rationale: The correct answer is B) Change to latex-free gloves when handling the infant. This is the most important action for the nurse to take because the child is showing signs of an allergic reaction, likely due to a latex allergy. Given that the child has myelomeningocele, which is a neural tube defect, they may have a higher risk of developing allergies. Using latex-free gloves will help prevent further exposure to latex and reduce the risk of exacerbating the allergic symptoms. Option A) Auscultate the lungs for respiratory pneumonia is incorrect because the symptoms described are indicative of an allergic reaction, not respiratory pneumonia. Option C) Draw blood to analyze for streptococcal infection is incorrect because the symptoms are not suggestive of a streptococcal infection but rather an allergic reaction. Option D) Apply zinc oxide to the perineum with each diaper change is incorrect because it addresses diaper rash, which is not the primary concern in this scenario. In an educational context, it is important for healthcare providers to be aware of common allergies, such as latex, especially when caring for vulnerable populations like infants with myelomeningocele. Understanding the signs and symptoms of allergic reactions and knowing how to manage them is crucial in providing safe and effective care.

Correct Answer: A

Rationale: In this scenario, the correct answer is option A: "Lower legs become progressively weaker, causing a waddling, unsteady gait." This characteristic of Duchenne muscular dystrophy (DMD) is crucial for the nurse to focus on during the initial teaching because it is a hallmark symptom of the disease. Understanding the progressive weakness in the lower extremities helps the nurse educate the family about mobility challenges the child may face, the need for assistive devices, and the importance of physical therapy to maintain function as long as possible. Option B, "Growth and development have been abnormal since birth," is incorrect because while DMD can impact growth and development due to muscle weakness, it is not the primary characteristic to focus on initially. Option C, "Muscular strength can be regained with physical exercise and therapy," is incorrect as DMD is a degenerative condition with progressive muscle weakness that cannot be reversed through exercise. Option D, "Respiratory dysfunction and aspiration are prime concerns at this stage of the disease," is incorrect as respiratory complications typically occur in later stages of DMD, not initially. Educationally, understanding the key clinical manifestations of DMD is essential for nurses caring for children with this condition. By focusing on the characteristic of progressive lower extremity weakness, nurses can provide targeted education and support to families to improve the child's quality of life and promote optimal function for as long as possible.

Correct Answer: B

Rationale: In this scenario, the correct nursing intervention is to "remove restraints one at a time to provide range of motion exercises" (Option B). This is the appropriate action because it promotes the child's comfort and prevents joint stiffness. By removing one restraint at a time, the nurse can assess the child's response, provide necessary care, and ensure proper circulation and skin integrity. Option A is incorrect because waiting for the healthcare provider's advice may delay necessary care and hinder the child's recovery. Option C is incorrect as it does not address the need for range of motion exercises or the potential risks associated with prolonged use of restraints. Option D is also incorrect as it does not prioritize providing range of motion exercises and may lead to skin breakdown if the restraints are left off for too long. Educationally, understanding the rationale behind the correct intervention is crucial for nurses caring for pediatric patients post-cleft lip repair. It is essential to prioritize the child's comfort, mobility, and overall well-being while considering the implications of restraint use. Nurses should be knowledgeable about appropriate interventions to promote optimal outcomes for their pediatric patients.

Correct Answer: B

Rationale: In the case of slipped femoral capital epiphysis, surgical intervention is often required. Post-surgery care is crucial to prevent complications such as infection and ensure proper healing. This care includes monitoring and managing pin and incision sites for signs of infection, promoting wound healing, and preventing postoperative complications. The focus on pin and incision care is essential for the child's recovery and overall well-being.