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:

The nurse should schedule a 3-hour oral glucose tolerance test (OGTT) for the client because the blood glucose levels taken 1 hour following a meal are higher than the expected range for gestational diabetes. This test will help to diagnose and assess the client's glucose tolerance and determine if there is gestational diabetes or any other potential glucose regulation issues.

Choice B rationale:

Increasing carbohydrates to 65% of daily nutritional intake is not the appropriate action in this situation. It may lead to further elevation of blood glucose levels, which can be detrimental for a client with gestational diabetes. The goal is to manage blood glucose levels and prevent complications, so recommending a higher carbohydrate intake would be counterproductive.

Choice C rationale:

Obtaining an HbA1c (glycated hemoglobin) is not the most suitable action in this scenario. HbA1c provides an average of the blood glucose levels over the past few months, which is more helpful for diagnosing and monitoring chronic diabetes, rather than gestational diabetes, which is temporary and occurs during pregnancy. An OGTT is a more appropriate test for gestational diabetes assessment.

Choice D rationale:

Reinforcing instruction about insulin administration is not warranted at this point since there is no information indicating that the client is currently on insulin therapy. Additionally, using insulin as the first step in the management of gestational diabetes is not common practice. Lifestyle modifications, dietary changes, and other measures are usually attempted first.

A. This medication destroys Rh antibodies in a newborn who is Rh-positive. B. This medication destroys Rh antibodies in a woman who is Rh-negative. C. This medication prevents the formation of Rh antibodies by a woman who is Rh-negative. D. This medication prevents the formation of RH antibodies in a newborn who is Rh-positive.

Correct Answer is C

Explanation

Choice A rationale:

This statement is incorrect because Rho(D) immune globulin does not destroy Rh antibodies in a newborn who is Rh-positive. Instead, it acts to prevent the development of Rh antibodies in the mother.

Choice B rationale:

This statement is also incorrect. Rho(D) immune globulin does not destroy Rh antibodies in a woman who is Rh-negative. It is given to Rh-negative women to prevent them from forming Rh antibodies in response to Rh-positive fetal blood during pregnancy.

Choice C rationale:

This is the correct choice. Rho(D) immune globulin is given to Rh-negative women to prevent the formation of Rh antibodies. If an Rh-negative woman is exposed to Rh-positive blood (usually during childbirth), her immune system may recognize the Rh antigen as foreign and start producing Rh antibodies. These antibodies could potentially cross the placenta during a subsequent pregnancy and attack the red blood cells of an Rh-positive fetus, causing hemolytic disease in the newborn. Rho(D) immune globulin helps prevent this sensitization process.

Choice D rationale:

This statement is incorrect. Rho(D) immune globulin does not prevent the formation of Rh antibodies in a newborn who is Rh-positive. Its main purpose is to protect Rh-negative women from forming antibodies that could harm future Rh-positive pregnancies.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is reviewing laboratory results from a client who is at 28 weeks of gestation and has gestational diabetes. The nurse notes that blood glucose levels taken 1 hr following a meal range from 145 mg/dL to 162 mg/dL over the past week. Which of the following actions should the nurse take?

Correct Answer is D

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?

Correct Answer is C

Explanation

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?

A nurse is assisting with the care of a client who is using pattern-paced breathing during the first stage of labor. The client says she feels lightheaded, and her fingers are tingling. Which of the following actions should the nurse take?

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.

A nurse is assisting with the care of a newborn following a vaginal delivery. Which of the following actions should the nurse perform first?

A nurse is reinforcing teaching with a client who is at 30 weeks of gestation and scheduled for a nonstress test (NST). Which of the following statements by the client indicates a need for further teaching?

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)