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
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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Related Questions
Correct Answer is C
Explanation
A. Hypoxemia is not directly associated with cephalohematoma.
B. Hypoglycemia is not a typical complication related to cephalohematoma.
C. A cephalohematoma can increase the risk of hyperbilirubinemia due to the breakdown of red blood cells in the hematoma, leading to increased bilirubin levels.
D. Hyperglycemia is not linked to cephalohematoma.
Correct Answer is A
Explanation
A. G4T1P2A1L3 correctly documents her four pregnancies (G4), one term birth (T1), two preterm births (P2), one abortion (A1), and three living children (L3).
B. G4T2P0A1L3 incorrectly suggests two term births and no preterm births.
C. G3T1P2A1L3 incorrectly suggests only three pregnancies.
D. G4T1P1A1L3 incorrectly indicates only one preterm birth.
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