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 C
Explanation
Choice A Reason: Macrosomic newborn. This is a correct answer that describes a possible complication of post-term pregnancy. A macrosomic newborn is a newborn that weighs more than 4000 grams or 8 pounds 13 ounces at birth. It can occur in post-term pregnancies due to prolonged exposure to maternal glucose and insulin. It can increase the risk of birth injuries, shoulder dystocia, cesarean delivery, and hypoglycemia.
Choice B Reason: Intrauterine growth restriction (IUGR). This is a correct answer that indicates a potential problem of post-term pregnancy. IUGR is a condition where the fetal growth is slower than expected for gestational age. It can occur in post-term pregnancies due to placental insufficiency, aging, or calcification, which can impair nutrient and oxygen delivery to the fetus. It can increase the risk of fetal distress, hypoxia, acidosis, and stillbirth.
Choice C Reason: Umbilical cord prolapse. This is an incorrect answer that does not reflect a risk of post-term pregnancy, but rather a risk of other factors such as prematurity, low birth weight, breech presentation, multiple gestation, polyhydramnios, or artificial rupture of membranes.
Choice D Reason: Meconium Aspiration Syndrome (MAS). This is a correct answer that denotes a possible complication of post-term pregnancy. 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. It can cause respiratory distress syndrome (RDS), persistent pulmonary hypertension (PPHN), or chronic lung disease (CLD).
Correct Answer is A
Explanation
Choice A Reason: Docusate sodium (Colace). This is because docusate sodium is a stool softener that can prevent constipation and straining during defecation, which can aggravate or impair the healing of a perineal laceration. A fourth-degree perineal laceration is a severe tear that extends through the skin, muscles, perineal body, and anal sphincter into the rectal mucosa. It can occur during vaginal delivery due to factors such as fetal macrosomia, forceps use, or episiotomy.
Choice B Reason: Bromocriptine (Parlodel). This is an inappropriate medication for a postpartum client with a fourth- degree perineal laceration, as it has no effect on wound healing or pain relief. Bromocriptine is a dopamine agonist that can suppress lactation by inhibiting prolactin secretion. It is used for women who do not wish to breastfeed or who have medical contraindications to breastfeeding.
Choice C Reason: Ferrous sulfate (Feosol). This is an unnecessary medication for a postpartum client with a fourth- degree perineal laceration, unless she has iron deficiency anemia. Ferrous sulfate is an iron supplement that can treat or prevent anemia by increasing hemoglobin production and oxygen-carrying capacity. Anemia can occur in the postpartum period due to blood loss during delivery or poor nutritional intake during pregnancy.
Choice D Reason: Methylergonovine (Methergine). This is an irrelevant medication for a postpartum client with a fourth-degree perineal laceration, as it does not affect wound healing or pain relief. Methylergonovine is an ergot alkaloid that can stimulate uterine contractions and reduce postpartum bleeding. It is used for women who have uterine atony or hemorrhage.
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