Which documentation in the health record is most correct for the third stage of labor?

Begins with the time of full cervical dilation (dilatation) and ends with the delivery of the fetus.

Begins with the time of placental delivery and ends 48 hours later.

Begins with the time of placental delivery and ends when the health care provider is satisfied that there are no placental fragments.

Begins with the time of delivery of the fetus and ends with the time of the delivery of the placenta.

Answer and Explanation

The Correct Answer is D

The correct answer is choice D.

Choice A rationale:

This statement describes the second stage of labor, not the third. The second stage begins with full cervical dilation and ends with the delivery of the fetus.

Choice B rationale:

The third stage of labor does not end 48 hours after the delivery of the placenta. This choice is incorrect.

Choice C rationale:

While it’s important to ensure no placental fragments remain, the third stage of labor technically ends with the delivery of the placenta, not at this later point.

Choice D rationale:

This is the correct definition of the third stage of labor. It begins with the delivery of the fetus and ends with the delivery of the placenta.

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Correct Answer is A

Explanation

The correct answer is choice A.

Choice A rationale:

Evaluating the firmness of the uterus (fundus) is the first action the nurse should take when a client’s blood pressure drops postpartum. A soft or “boggy” uterus can indicate uterine atony, a leading cause of postpartum hemorrhage, which can lead to hypotension.

Choice B rationale:

Obtaining a type and crossmatch is important if the client needs a blood transfusion, but it is not the first action the nurse should take.

Choice C rationale:

Administering oxytocin infusion can help contract the uterus and control bleeding, but the nurse should first assess the uterus.

Choice D rationale:

Initiating oxygen therapy can help if the client is hypoxic, but the nurse should first assess the uterus.

A. Focus on the family unit and its members. B. Expressions of excitement. C. Eagerness to learn newborn care skills. D. Lack of appetite.

Correct Answer is B

Explanation

The correct answer is choice B.

Choice A rationale:

Focus on the family unit and its members is more characteristic of the “letting-go” phase.

Choice B rationale:

Expressions of excitement are common in the dependent, taking in phase as the mother is focused on her own needs and the experience of childbirth.

Choice C rationale:

Eagerness to learn newborn care skills is more characteristic of the “taking-hold” phase.

Choice D rationale:

Lack of appetite is not a typical characteristic of the dependent, taking in phase.

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Which documentation in the health record is most correct for the third stage of labor?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who gave birth 2 hr ago.The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?.

Correct Answer is A

Explanation

A nurse is caring for a client who experienced a vaginal birth 12 hr ago.The nurse recognizes the client is in the dependent, taking in phase of maternal postpartum adjustment.Which of the following findings should the nurse expect during this phase?.

Correct Answer is B

Explanation

A nurse is assessing a postpartum woman.Which behavior would the nurse interpret as an indication that the woman is entering the taking-hold phase of the postpartum period?

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A nurse is caring for a client who is at 36 weeks of gestation and who has a suspected placenta previa.Which of the following findings support this diagnosis?.

When reviewing the medical record of a postpartum client, the nurse notes that the client has experienced a fourth-degree laceration.The nurse understands that the laceration extends to which area?.

A nurse is caring for a client who just delivered a newborn.Following the delivery, which nursing action should be done first to care for the newborn?

A nurse midwife is examining a client who is a primigravida at 42 weeks of gestation and states that she believes she is in labor.Which of the following findings confirm to the nurse that the client is in labor?.

A client in the third stage of labor has experienced placental separation and expulsion.Why is it necessary for a nurse to massage the woman's uterus briefly until it is firm?.

A nurse is caring for a client on the second day postpartum.The client informs the nurse that she is voiding a large volume of urine frequently.Which factor should the nurse identify as a potential cause for urinary frequency?.