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Which action is a priority when caring for a woman during the fourth stage of labor?.

Offering fluids as indicated.

Encouraging the woman to void.

Assessing the uterine fundus.

Assisting with perineal care.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Offering fluids is important to prevent dehydration, but it’s not the priority during the fourth stage of labor.

Choice B rationale:

Encouraging the woman to void can help prevent urinary retention, but it’s not the priority.

Choice C rationale:

Assessing the uterine fundus is the priority during the fourth stage of labor. This is to ensure that the uterus is contracting and to prevent postpartum hemorrhage.

Choice D rationale:

Assisting with perineal care is important for comfort and hygiene, but it’s not the priority.

So, the correct answer is C, assessing the uterine fundus.

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Correct Answer is D

Explanation

Choice A rationale:

Notifying the primary care provider is important but not the immediate next step. The nurse has other immediate responsibilities to ensure the safety of the mother and baby.

Choice B rationale:

A vaginal exam could introduce bacteria into the uterus and is not the immediate next step after rupture of membranes.

Choice C rationale:

Changing the linen saver pad is not the immediate next step. While it might be necessary for the comfort of the mother, it does not address the potential risks associated with rupture of membranes.

Choice D rationale:

Checking the fetal heart rate is the correct next step. This ensures that the baby is not in distress following the rupture of membranes.

A. Intercourse at this time is likely to cause rupture of membranes. B. Intercourse at this time is likely to result in premature labor. C. It is safe to have intercourse at this time. D. There are other ways that the couple can satisfy their needs.

Correct Answer is C

Explanation

Choice A rationale:

This is incorrect. Intercourse is unlikely to cause rupture of membranes.

Choice B rationale:

This is also incorrect. Intercourse is not likely to result in premature labor.

Choice C rationale:

This is correct. It is generally safe to have intercourse during an uneventful pregnancy.

Choice D rationale:

This is also correct. There are other ways to satisfy sexual needs if intercourse is not possible or desired.

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Which action is a priority when caring for a woman during the fourth stage of labor?.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a contraction. What would the nurse do next?

Correct Answer is D

Explanation

A woman in the 34th week of pregnancy says to the nurse, "I still feel like having intercourse with my husband.”. The woman's pregnancy has been uneventful. The nurse responds based on the understanding that:.

Correct Answer is C

Explanation

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