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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: Possible Meconium Aspiration Syndrome (MAS). This is an unlikely condition for this newborn, as MAS occurs when fetal stool (meconium) enters into the lungs before or during birth, causing airway obstruction, inflammation, and infection. MAS usually affects term or post-term infants who experience fetal distress or hypoxia in utero.
Choice B Reason: Possible polycythemia. This is an unrelated condition for this newborn, as polycythemia refers to an abnormally high number of red blood cells in the blood, which can increase blood viscosity and impair circulation.
Polycythemia may occur in infants who have delayed cord clamping, intrauterine growth restriction, maternal diabetes, or high altitude exposure.
Choice C Reason: Possible Transient Tachypnea of the Newborn (TTN). This is a less serious condition than RDS, as TTN is a mild respiratory problem that results from delayed clearance of fetal lung fluid after birth. TTN causes rapid breathing, nasal flaring, grunting, and mild cyanosis. It usually resolves within 24 to 48 hours after birth.
Choice D Reason: Possible Respiratory Distress Syndrome (RDS). This is a serious condition that requires immediate intervention and treatment, as RDS can lead to life-threatening complications such as pulmonary hemorrhage, pneumothorax, or bronchopulmonary dysplasia. RDS causes respiratory distress, nasal flaring, retractions, grunting, and central cyanosis. It usually occurs within minutes to hours after birth.
Correct Answer is B
Explanation
Choice A Reason: Physiologic anemia due to maternal increased plasma volume. This is an incorrect answer that refers to a different condition that affects hemoglobin levels, not blood pressure. Physiologic anemia is a condition where the maternal plasma volume increases more than the red blood cell mass during pregnancy, which dilutes the hemoglobin concentration and lowers the hematocrit value. Physiologic anemia does not cause significant symptoms or complications in pregnant women, as it is an adaptive mechanism that enhances oxygen delivery and prevents fluid overload.
Choice B Reason: Pressure of the gravid uterus on the maternal inferior vena cava and aorta. This is because this statement explains the cause of supine hypotensive syndrome, which is a condition where lying flat on the back causes compression of the major blood vessels by the gravid uterus, which reduces venous return and cardiac output, which lowers blood pressure and perfusion to vital organs. Supine hypotensive syndrome can cause symptoms such as dizziness, lightheadedness, nausea, pallor, or syncope in pregnant women, especially in the third trimester.
Choice C Reason: Pressure of the presenting fetal part on the maternal diaphragm. This is an incorrect answer that indicates a different condition that affects respiratory function, not blood pressure. Pressure of the presenting fetal part on the maternal diaphragm is a result of cephalic engagement or lightening, which occurs when the fetal head descends into the pelvis and occupies more space in the abdominal cavity. Pressure of the presenting fetal part on the maternal diaphragm can cause symptoms such as dyspnea, heartburn, or rib pain in pregnant women.
Choice D Reason: A 50% increase in maternal blood volume during pregnancy. This is an incorrect answer that describes a normal physiological change that occurs during pregnancy, not a cause of supine hypotensive syndrome. A 50% increase in maternal blood volume during pregnancy is due to increased production of plasma and red blood cells, which helps meet the increased oxygen and nutrient demands of the fetus and placenta, and prepares the mother for blood loss during delivery. A 50% increase in maternal blood volume during pregnancy does not cause hypotension or dizziness in pregnant women.
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