A primigravida client is in the fourth stage of labor after the delivery of a newborn male infant.
Which information should the nurse provide?

Bulb syringe use.

Newborn screening tests.

Techniques to breastfeed.

Circumcision care.

Answer and Explanation

The Correct Answer is C

Choice A rationale

While bulb syringe use is important for clearing the newborn's airways, it is not the immediate priority during the fourth stage of labor. This information can be provided later during routine newborn care education.

Choice B rationale

Newborn screening tests are important for identifying potential health issues, but the fourth stage of labor is focused on stabilizing the mother and infant and initiating breastfeeding. Screening information can be shared during the postpartum period.

Choice C rationale

Techniques to breastfeed are critical information to provide during the fourth stage of labor as it helps establish successful breastfeeding early on. This support can enhance maternal-infant bonding and promote breastfeeding success.

Choice D rationale

Circumcision care is relevant for parents who choose to circumcise their infant, but it is not the immediate priority during the fourth stage of labor. This information can be provided during subsequent postpartum visits.

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Correct Answer is C

Explanation

Choice A rationale

Infusing 1,000 mL normal saline using a large bore IV is a good response to increase the client's blood volume and improve blood pressure, but it should not be the first action. The immediate priority is to relieve the compression of the inferior vena cava caused by the gravid uterus, which is decreasing blood return to the heart and causing hypotension.

Choice B rationale

Obtaining a blood sample for a complete blood count is important for assessing the client's overall health and identifying any possible complications, but it does not address the immediate life-threatening issue of hypotension caused by the gravid uterus compressing the inferior vena cava.

Choice C rationale

Tilting the backboard sideways to displace the uterus laterally is the correct first action. This maneuver helps to relieve the compression of the inferior vena cava by the gravid uterus, thereby improving blood return to the heart, increasing cardiac output, and normalizing blood pressure.

Choice D rationale

Palpating the abdomen for contractions is important to assess for potential labor or uterine irritability, but it does not address the immediate need to relieve the compression of the inferior vena cava causing hypotension.

A. Perform a vaginal exam. B. Take vital signs. C. Palpate the bladder. D. Examine the amniotic fluid. E. Dipstick urine for protein and ketones.

Correct Answer is ["A","B"]

Explanation

Choice A rationale

Performing a vaginal exam is crucial in assessing the progress of labor and the condition of the cervix, particularly if the client has reported symptoms such as contractions, bleeding, or fluid leakage. It helps determine if the client is in active labor or if there are any complications requiring immediate intervention.

Choice B rationale

Taking vital signs is essential to assess the client's overall health and identify any signs of distress or complications. Vital signs provide critical information about the client's cardiovascular and respiratory status, which is important for immediate clinical decision-making.

Choice C rationale

Palpating the bladder is important in assessing for bladder distention, which can impede labor progress or cause discomfort. However, it is not the immediate priority compared to assessing labor progress and overall health status.

Choice D rationale

Examining the amniotic fluid is important for determining its characteristics, which can provide information about the fetal well-being. However, this action is secondary to performing a vaginal exam and taking vital signs in the immediate assessment.

Choice E rationale

Dipstick urine for protein and ketones helps in assessing for preeclampsia or gestational diabetes, but it does not address the immediate need to assess labor progress and the client's overall health status.

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A primigravida client is in the fourth stage of labor after the delivery of a newborn male infant.Which information should the nurse provide?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The nurse determines the need to perform further assessment based on the client's situation.Select the 2 actions that the nurse should perform immediately.

Correct Answer is ["A","B"]

Explanation

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A primigravida client is in the fourth stage of labor after the delivery of a newborn male infant.
Which information should the nurse provide?