Normal pregnancy

Which is the nurse's priority assessment for a client in the fourth stage of labor? 1-Degree of relaxation 2-Distention of the bladder 3-Extent of breast engorgement 4-Presence of mother-infant bonding

2-Distention of the bladder Rational: A distended bladder impedes contraction of the uterus, predisposing the client to hemorrhage. Relaxation is a priority before birth; in the fourth stage the client is often euphoric. It is too soon to assess breast engorgement because it occurs on the third or fourth postpartum day. It is too soon to assess bonding; this progresses with care and responsibility. Topics

A nurse is caring for a client going into the fourth stage of labor. Which is the priority nursing assessment during this​ stage? 1-Assessing vital signs every 1 hr 2-Assessing pulse oximetry every 4 hr 3-Assessing the uterus 4-Assessing vaginal discharge every 4 hr

3- Assessing the uterus Rationale During the fourth stage of​ labor, the uterus should be firm and midline in the abdomen about midway between the symphysis pubis and umbilicus. In the fourth stage of​ labor, nurses can expect changes in the maternal vital signs. Expect to perform assessments every 15 min ​×​ 4, then every 30 min ​×​ 2, then every 1 hr until stable. There should be moderate vaginal drainage​ (lochia rubra). The woman may report feeling​ chilly, thirsty,​ hungry, and tired.

Which action would the nurse take when a 15-beat-per-minute acceleration of the fetal heart rate above the baseline occurs during a contraction? 1-Call the practitioner to prepare for an imminent birth. 2-Turn the mother on her left side to increase venous return. 3-Record the fetal response to contractions and continue to monitor the heart rate. 4-Document the fetal heart rate abnormality and monitor the fetal heart rate continuously.

3-Record the fetal response to contractions and continue to monitor the heart rate. Rational Periodic accelerations are the most reassuring of fetal heart rate indicators, regardless of the cause. The fetal response is recorded and monitoring continues unchanged. This increase in the fetal heart rate does not require intervention by the practitioner at this time. Turning the mother on her left side to increase venous return is done when a fetal heart rate deceleration occurs. This acceleration is not a fetal heart rate abnormality and does not require a specific frequency of monitoring.

Where would the nurse expect the fundus to be located 3 days after a cesarean birth? 1- one fingerbreadth below the umbilicus 2-Two fingerbreadths below the umbilicus 3-Three fingerbreadths below the umbilicus 4-Four fingerbreadths below the umbilicus

3-Three fingerbreadths below the umbilicus Rational: The fundus descends 1 fingerbreadth per day from the first postpartum day. So 3 days after birth, the fundus would be 3 fingerbreadths below the umbilicus. If the fundus is 1 or 2 fingerbreadths below the umbilicus, the nurse should suspect that involution has been delayed, and further investigation is required. Although a fundus 4 fingerbreadths below the umbilicus is not expected, it is a benign occurrence.

Which nutritional deficiency in pregnant women places the infant at risk for malformations of the central nervous system? 1-Zinc 2-Sodium 3-Potassium 4-Magnesium

1- Zinc Zinc deficiency in pregnant women is associated with malformations of the central nervous system in infants. Malformations of the central nervous system in infants are not associated with sodium, potassium, or magnesium deficiencies in pregnant women.