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.
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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Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
Choice A rationale:
Vaginal hematoma is not a common complication in the 4th stage of labor. This stage primarily involves the recovery and stabilization of the mother after delivery.
Choice B rationale:
Hypoglycemia is not a typical complication in the 4th stage of labor. While blood glucose levels might be monitored during labor, the risk of hypoglycemia is generally higher in neonates, especially if the mother has diabetes.
Choice C rationale:
Chorioamnionitis is an infection of the fetal membranes and amniotic fluid, typically diagnosed during labor or shortly after delivery. It is not specific to the 4th stage of labor.
Choice D rationale:
Uterine hemorrhage is the most significant concern during the 4th stage of labor, also known as the "postpartum”. or "recovery”. stage. It refers to excessive bleeding from the site where the placenta detached. This bleeding can be life-threatening if not managed promptly.
Choice E rationale:
Dehiscence is the separation of surgical incisions, which is not a common complication during the 4th stage of labor.
Correct Answer is C
Explanation
The correct answer is choice C. Assist the client to breathe into a paper bag.
Choice A rationale:
Instructing the client to maintain a breathing rate no less than twice the normal rate is not appropriate. This could exacerbate hyperventilation, leading to further lightheadedness and tingling.
Choice B rationale:
Administering oxygen via nasal cannula is not necessary in this situation. The symptoms are due to hyperventilation, not a lack of oxygen.
Choice C rationale:
Assisting the client to breathe into a paper bag helps to rebreathe carbon dioxide, which can correct the respiratory alkalosis caused by hyperventilation. This will alleviate the symptoms of lightheadedness and tingling.
Choice D rationale:
Having the client tuck her chin to her chest is not a recognized intervention for hyperventilation. It would not address the underlying issue of respiratory alkalosis.
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