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At the beginning of the fourth stage of labor the nurse assess what four things? (Select four correct answers).

Fundal tone

Lochia

Transcutaneous bilirubin

Engorgement

Vital Signs

Bladder distension

Answer and Explanation

Correct Answer : A,B,E,F

A. Fundal tone assessment helps detect uterine atony.

B. Lochia assessment monitors postpartum bleeding.

C. Transcutaneous bilirubin is not assessed in the immediate postpartum period.

D. Engorgement relates to breastfeeding and is not a priority in the fourth stage.

E. Vital signs are crucial to monitor for hemorrhage or shock.

F. Bladder distension can affect uterine contraction and bleeding.

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Correct Answer is B

Explanation

A. Rhogam is usually given at 28 weeks of pregnancy, not 4 days after delivery.

B. Rh-negative mothers who have had an Rh-positive baby are typically given Rhogam at 28 weeks gestation to prevent Rh sensitization. Rhogam is also given after delivery if the baby is Rh-positive.

C. Rhogam is necessary for Rh-negative women who have had an Rh-positive baby, as it helps prevent Rh sensitization in subsequent pregnancies.

D. Only the baby is at risk for Rh incompatibility, not the partner.

A. If she has had prenatal care. B. Membrane status and her EDD/EDC. C. Time of last food intake and fasting blood sugar. D. Pain level and birth plan.

Correct Answer is B

Explanation

A. Prenatal care history is important but not as urgent as membrane status and estimated delivery date.

B. Membrane status and estimated delivery date are critical for assessing the stage of labor and planning care.

C. Fasting blood sugar is relevant in diabetic patients but not an immediate priority.

D. Pain level and birth plan are important but secondary to assessing labor progress.

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At the beginning of the fourth stage of labor the nurse assess what four things? (Select four correct answers).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A woman is RH neg and pregnant. Her previous baby was Rh positive. The nurse would be correct in telling her which of the following information?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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