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 B
Explanation
Choice A Reason: "If I try to talk to my partner during a contraction, I can't." This is an incorrect answer that indicates a sign of true labor, not false labor. True labor is a condition where there are regular and painful uterine contractions that cause cervical dilation and effacement, and lead to delivery of the baby and placenta. True labor contractions are usually strong and consistent, and they tend to increase or persist with activity or position changes. True labor contractions can be so intense that they interfere with speech or breathing.
Choice B Reason: ) "My contractions slow down when I walk around." This is because this statement by the client would lead the nurse to suspect that the woman is experiencing false labor, which is also known as Braxton Hicks contractions or practice contractions. False labor is a condition where there are irregular and painless uterine contractions that do not cause cervical dilation or effacement. False labor can occur throughout pregnancy, but it becomes more noticeable and frequent in late pregnancy. False labor contractions are usually weak and inconsistent, and they tend to decrease or stop with activity or position changes.
Choice C Reason: "I feel contractions start mostly in my back and they sweep around to the top of my abdomen." This is an incorrect answer that indicates a sign of true labor, not false labor. True labor contractions usually start in the lower back and radiate to the lower abdomen or groin, following a wave-like patern. False labor contractions are more likely to be felt in the upper abdomen or sides, without a clear patern.
Choice D Reason: "My contractions are about 6 minutes apart and regular." This is an incorrect answer that indicates a sign of true labor, not false labor. True labor contractions usually have a regular frequency and duration, and they become closer and longer as labor progresses. False labor contractions are more likely to have an irregular frequency and duration, and they do not change significantly over time.
Correct Answer is B
Explanation
Choice A Reason: The cheek of the newborn is touched, and the newborn turns toward the side that was touched. This is an incorrect answer that describes a different reflex called the rooting reflex. The rooting reflex is a feeding reflex that helps the newborn locate the nipple and initiate sucking. The rooting reflex is elicited by stroking the cheek or corner of the mouth of the newborn, which causes them to turn their head and open their mouth toward the stimulus.
Choice B Reason: The newborn is suddenly lowered or startled, and they extend their arms, legs and neck, then rapidly bring their arms together. This is because this response describes the Moro reflex, which is a primitive reflex that is present at birth and disappears by 3 to 6 months of age. The Moro reflex is elicited by simulating a falling sensation or a loud noise, which triggers a fear response in the newborn. The Moro reflex consists of four phases: extension, abduction, adduction, and crying.
Choice C Reason: The newborn is supine and their head is turned to one side, then the arm on that same side extends. This is an incorrect answer that refers to another reflex called the tonic neck reflex. The tonic neck reflex is a postural reflex that helps prepare the newborn for voluntary reaching. The tonic neck reflex is elicited by placing the newborn in a supine position and turning their head to one side, which causes them to assume a "fencing" posture with one arm extended and one arm flexed.
Choice D Reason: The lateral aspect of the sole of the newborn's foot is stroked, and the toes extend and fan outward. This is an incorrect answer that indicates a different reflex called the Babinski reflex. The Babinski reflex is a neurological reflex that tests for spinal cord integrity. The Babinski reflex is elicited by stroking the lateral aspect of the sole of the foot from heel to toe, which causes the big toe to dorsiflex and the other toes to fan out.
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