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 D

Explanation

Choice A rationale:

Increasing the rate of the maintenance IV infusion may be a rational action in some situations, but it is not the first priority when dealing with a fetal heart rate deceleration. The priority is to address the deceleration and potential fetal distress promptly.

Choice B rationale:

Administering oxygen using a nonrebreather mask might be beneficial for the client, but it is not the primary action to take when dealing with fetal heart rate deceleration. The priority is to address the deceleration and ensure fetal well-being.

Choice C rationale:

Elevating the client's legs is unlikely to have a significant impact on fetal heart rate deceleration. This action is more relevant in cases of maternal hypotension or when trying to improve venous return to the heart. It is not the first-line intervention for fetal heart rate decelerations.

Choice D rationale:

Placing the client in the lateral (side-lying) position is the correct action to take first. This position can help relieve pressure on the vena cava, improve blood flow, and increase oxygen supply to the fetus. By changing the client's position, the nurse can potentially resolve the fetal heart rate deceleration and improve fetal well-being.

A. Preterm labor. B. Infection. C. Profound bleeding. D. Rupture of the fetal membranes.

Correct Answer is C

Explanation

Choice A rationale:

Preterm labor. Performing a pelvic examination in a client with placenta previa can potentially trigger uterine contractions, leading to preterm labor. Manipulating the cervix during the examination may stimulate the release of hormones that could initiate labor, putting both the mother and the baby at risk.

Choice B rationale:

Infection. While infection is a valid concern in any medical procedure, it is not the primary rationale for avoiding a pelvic examination in a client with placenta previa. The primary concern is the risk of severe bleeding caused by the disruption of the placenta's attachment to the uterine wall.

Choice C rationale:

Profound bleeding. The primary rationale to avoid a pelvic examination in a client with placenta previa is the risk of profound bleeding. Placenta previa occurs when the placenta covers part or all of the cervix, and it is at risk of being damaged or detached during a pelvic exam. This can lead to life-threatening hemorrhage for both the mother and the baby.

Choice D rationale:

Rupture of the fetal membranes. While this complication is possible during a pelvic examination, it is not the primary rationale to avoid the procedure in a client with placenta previa. The main concern, as mentioned before, is the risk of severe bleeding that can occur due to placental disruption.

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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

Correct Answer is D

Explanation

A nurse is assisting with the care of a client who is at 37 weeks of gestation and has placenta previa. Which of the following risks is the primary rationale the nurse should avoid performing a pelvic examination?

Correct Answer is C

Explanation

A nurse is caring for a client who is pregnant in a provider's office. Exhibits Which of the following findings should the nurse report to the provider? (Select all that apply)

A nurse is caring for a client who is at 36 weeks of gestation and has suspected placenta previa. For which of the following findings should the nurse monitor the client?

A nurse is reinforcing teaching with a client who is pregnant and has a new prescription for ferrous sulfate due to iron-deficiency anaemia. The nurse should instruct the client to take this medication with which of the following?

A nurse is assisting with the care of a client who is receiving oxytocin via IV infusion following a vaginal delivery. Which of the following findings should the nurse monitor to evaluate the effectiveness of this medication?

A nurse in a provider's office is reinforcing teaching about home care with a client who has mild preeclampsia. Which of the following information should the nurse include in the teaching?

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.