A woman has just entered the third stage of labor. The nurse would focus care on which of the following? Select one:

Assisting with the delivery of the placenta and ensuring that the fundus is contracted afterward.

Palpating the woman's fundus for position and firmness.

Encouraging the woman to push with her contractions.

Alleviating perineal discomfort with the application of ice packs.

Answer and Explanation

The Correct Answer is A

Choice A Reason: Assisting with the delivery of the placenta and ensuring that the fundus is contracted afterward. This is an appropriate action for the nurse to perform during the third stage of labor, as it helps complete the process of labor and prevent complications.

Choice B Reason: Palpating the woman's fundus for position and firmness. This is an action that is done after the delivery of the placenta, not during. It is important to monitor the fundal height, location, and consistency to assess uterine involution and bleeding.

Choice C Reason: Encouraging the woman to push with her contractions. This is an action that is done during the second stage of labor, not the third. The second stage of labor is the period from full cervical dilation to the birth of the baby. The nurse's role is to support and coach the woman to push eﬀectively with her contractions.

Choice D Reason: Alleviating perineal discomfort with the application of ice packs. This is an action that is done after the delivery of the placenta, not during. It is a comfort measure that can reduce swelling, pain, and inﬂammation in the perineal area.

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Correct Answer is D

Explanation

Choice A Reason: Moderate amounts of deep red lochia. This is not a finding that would warrant further investigation, but rather a normal finding for the early postpartum period. Lochia is the vaginal discharge that occurs after delivery, which consists of blood, mucus, and tissue from the uterus. Lochia is usually deep red in color and moderate in amount for the first few days after delivery.

Choice B Reason: Sweating while afebrile. This is not a finding that would warrant further investigation, but rather a common occurrence in the postpartum period. Sweating is a mechanism of thermoregulation that helps the body eliminate excess ﬂuid and electrolytes that were retained during pregnancy. Sweating does not necessarily indicate fever or infection.

Choice C Reason: Voiding 350 mL of blood-tinged urine. This is not a finding that would warrant further investigation, but rather an expected outcome for the postpartum period. Voiding large amounts of urine is normal in the postpartum period, as the body eliminates the excess ﬂuid that was accumulated during pregnancy. Blood-tinged urine may be due to trauma or irritation of the urinary tract during labor or delivery, which usually resolves within a few days.

Choice D Reason: Heart rate of 115 beats/minute. This is because a heart rate of 115 beats/minute is higher than the normal range for an adult, which is 60 to 100 beats/minute. A high heart rate may indicate postpartum hemorrhage, infection, pain, anxiety, or dehydration. The nurse should further assess the client for other signs and symptoms of these conditions and notify the physician if necessary.

A. Vascular spider veins. B. Linea nigra. C. Melasma. D. Striae gravidarum.

Correct Answer is B

Explanation

Choice A Reason: Vascular spider veins. This is an incorrect answer that refers to a diﬀerent skin change that occurs during pregnancy, which aﬀects the blood vessels, not the pigment. Vascular spider veins are small red or purple clusters of blood vessels that appear on the skin, especially on the face, neck, chest, or legs. Vascular spider veins are caused by increased blood volume and hormonal changes, which dilate and rupture the capillaries. Vascular spider veins are harmless and usually disappear after delivery.

Choice B Reason: Linea nigra. This is because linea nigra is a term that refers to a darkened vertical line that appears on the abdomen during pregnancy, which runs from the umbilicus to the pubis. Linea nigra is caused by increased production of melanin, which is a pigment that gives color to the skin and hair. Linea nigra is more common and noticeable in women with darker skin tones, and it usually fades after delivery.

Choice C Reason: Melasma. This is an incorrect answer that refers to a diﬀerent skin change that occurs during pregnancy, which aﬀects the pigment, but not in a linear patern. Melasma is a term that refers to patches of brown or gray-brown discoloration that appear on the face, especially on the forehead, cheeks, nose, or upper lip. Melasma is also caused by increased production of melanin, but it is inﬂuenced by sun exposure and genetic factors. Melasma is also known as chloasma or the mask of pregnancy, and it may persist after delivery.

Choice D Reason: Striae gravidarum. This is an incorrect answer that refers to a diﬀerent skin change that occurs during pregnancy, which aﬀects the connective tissue, not the pigment. Striae gravidarum are stretch marks that appear on the skin, especially on the abdomen, breasts, hips, or thighs. Striae gravidarum are caused by rapid growth and stretching of the skin, which damage the collagen and elastin fibers. Striae gravidarum are initially red or purple, but they fade to white or silver after delivery.

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A woman has just entered the third stage of labor. The nurse would focus care on which of the following? Select one:

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Naxlex Comprehensive Predictor Exams

When the nurse is assessing a postpartum client approximately 6 hours after delivery, which finding would warrant further investigation? Select one:

Correct Answer is D

Explanation

Assessment of a pregnant woman reveals a pigmented vertical line between the umbilicus and the pubis. The nurse documents this finding as: Select one:

Correct Answer is B

Explanation

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