When contributing to the plan of care for the 4th stage of labor, the nurse should recognize the client is at the greatest risk of developing which of the following complications?

Vaginal hematoma.

Hypoglycemia.

Chorioamnionitis.

Uterine hemorrhage.

Dehiscence.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Vaginal hematoma is not the most significant risk in the 4th stage of labor. While vaginal hematomas can occur due to trauma during delivery, they are less common and usually manageable compared to other complications.

Choice B rationale:

Hypoglycemia is not a typical complication in the 4th stage of labor. This stage refers to the immediate postpartum period, during which the mother's blood sugar levels may decrease slightly, but it is not the greatest concern at this stage.

Choice C rationale:

Chorioamnionitis is an infection of the fetal membranes and amniotic fluid. While it can be a concern during labor, the question specifically refers to the 4th stage, which occurs after the delivery of the placenta. Chorioamnionitis is more relevant to earlier stages of labor.

Choice D rationale:

Uterine hemorrhage is the greatest risk during the 4th stage of labor. This stage, also known as the "placental stage,”. is when the uterus contracts to expel the placenta. If the uterus fails to contract adequately, it can lead to significant bleeding, known as postpartum hemorrhage. This is a critical concern that requires immediate attention to prevent complications.

Choice E rationale:

Dehiscence, which refers to the reopening of a surgical wound, is not a common complication during the 4th stage of labor. The 4th stage primarily focuses on uterine contraction and placental delivery, making dehiscence less relevant in this context.

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Correct Answer is B

Explanation

Choice A rationale:

If the client is Rh positive and the newborn is Rh negative, there is no indication for administering Rho(D) immune globulin. Rho(D) immune globulin is only given when the Rh-negative mother gives birth to an Rh-positive baby.

Choice B rationale:

This is the correct choice for administering Rho(D) immune globulin. When the mother is Rh negative and the newborn is Rh positive, there is a risk of Rh incompatibility. If the fetal blood enters the mother's circulation during delivery, her immune system may produce antibodies against Rh-positive blood cells, which can be harmful to future Rh-positive pregnancies. To prevent this, Rho(D) immune globulin is administered to the Rh-negative mother shortly after delivery.

Choice C rationale:

If both the mother and the newborn are Rh-negative, there is no risk of Rh incompatibility. Rho(D) immune globulin is not required in this situation.

Choice D rationale:

If both the mother and the newborn are Rh-positive, there is no risk of Rh incompatibility. Rho(D) immune globulin is not indicated in this case.

A. Fetal head compression. B. Umbilical cord compression. C. Maternal fever. D. Polyhydramnios.

Correct Answer is B

Explanation

Choice A rationale:

Choice A, fetal head compression, is not the correct answer in this case. Fetal head compression can cause early decelerations in the FHR, not variable decelerations. Early decelerations are often a result of the fetal head being compressed during contractions and are considered benign and expected during labor.

Choice B rationale:

The correct answer is choice B, which is umbilical cord compression. Variable decelerations of the fetal heart rate (FHR) can occur during labor due to various rationales, and umbilical cord compression is one of the common causes. When the umbilical cord gets compressed, it can briefly reduce or restrict the blood flow and oxygen supply to the fetus, leading to temporary decelerations in the FHR.

Choice C rationale:

Choice C, maternal fever, is also not the correct answer for variable decelerations in FHR. Maternal fever can be a sign of infection, and it may lead to other fetal heart rate abnormalities, such as tachycardia (an increased heart rate), but it is not specifically associated with variable decelerations.

Choice D rationale:

Choice D, polyhydramnios, is not the cause of variable decelerations in this scenario. Polyhydramnios refers to an excessive accumulation of amniotic fluid around the fetus. While it can have implications for pregnancy, it is not directly linked to variable decelerations of the FHR.

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When contributing to the plan of care for the 4th stage of labor, the nurse should recognize the client is at the greatest risk of developing which of the following complications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postpartum. Which of the following findings is an indication for the nurse to administer Rho(D) immune globulin?

Correct Answer is B

Explanation

A nurse is assisting in the care of a client who is in active labour. The nurse notes variable decelerations of the FHR. The nurse should identify which of the following is a cause of variable decelerations.

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a client who is pregnant and has a prescription for Rho(D) immune globulin. Which of the following information should the nurse include?

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A nurse is assisting in the care of a client who is 36 weeks of gestation and reported to the clinic for a routine visit. Exhibits Which of the following findings should the nurse report to the provider? (Select all that apply)

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A nurse is admitting a client who is at 36 weeks gestation and has painless, bright red vaginal bleeding. The nurse recognizes this finding as an indication of which of the following conditions?

A nurse is caring for a client who is experiencing shaking chills during the immediate postpartum period. Which of the following actions should the nurse take?

A nurse is assisting with the care of a client who is at 32 weeks of gestation and in labor. The client asks the nurse, "Will my baby be okay?”. Which of the following responses should the nurse make?