The nurse is preparing to receive a newly delivered client. The ...

[nenivikky]

The nurse is preparing to receive a newly delivered client. The client is a young single mother who is relinquishing custody of her newborn through an open adoption. What action is most important?
 
  1. Assign the client a room on the GYN surgical floor instead of the postpartum floor.
  2. Prepare to have teaching done in time for discharging the client at 24 hours post-delivery.
  3. Make an effort to not bring up the topic of the baby, and discuss the mother's health instead.
  4. Ask the client if she wants to feed her baby, and how much contact she wants to have.

Question 2

The client presents to Labor and Delivery stating that her water broke two hours ago. Indicators of normal labor include: (Select all that apply.)
 
  1. Fetal heart rate of 130 with average variability.
  2. Blood pressure of 130/80.
  3. Maternal pulse of 160.
  4. Protein of +1 in urine.
  5. Odorless, clear fluid on underwear.

[harveenkau8139]

Answer to Question 1

4
Rationale:
1. Clients relinquishing their newborns should be given options for what their contact with the infant will be and where they would feel most comfortable. Make no assumptions, but assess instead.
2. Not all clients who relinquish their infants want early discharge. Make no assumptions, but assess instead.
3. It is the preferences of the client that determine how much she wants to talk about her birth, her newborn, or her decision to relinquish the child. Make no assumptions, but assess instead.
4. Assess the client's preferences by respectfully asking questions and making no assumptions to facilitate a more positive experience for the birth mother.

Answer to Question 2

1, 2, 5
Rationale:
1. FHR 120160 with variability is a normal indication.
2. Maternal vital sign of blood pressure below 140/70 is a normal indication.
3. A pulse of 60100 is a normal indication.
4. Proteinuria of +1 or more could be a sign of pre-eclampsia.
5. Fluid clear and without odor is a normal indication.