A woman has just entered the third stage of labor. The nurse would focus care on which of the following? Select one:
Assisting with the delivery of the placenta and ensuring that the fundus is contracted afterward.
Palpating the woman's fundus for position and firmness.
Encouraging the woman to push with her contractions.
Alleviating perineal discomfort with the application of ice packs.
The Correct Answer is A
Choice A Reason: Assisting with the delivery of the placenta and ensuring that the fundus is contracted afterward. This is an appropriate action for the nurse to perform during the third stage of labor, as it helps complete the process of labor and prevent complications.
Choice B Reason: Palpating the woman's fundus for position and firmness. This is an action that is done after the delivery of the placenta, not during. It is important to monitor the fundal height, location, and consistency to assess uterine involution and bleeding.
Choice C Reason: Encouraging the woman to push with her contractions. This is an action that is done during the second stage of labor, not the third. The second stage of labor is the period from full cervical dilation to the birth of the baby. The nurse's role is to support and coach the woman to push effectively with her contractions.
Choice D Reason: Alleviating perineal discomfort with the application of ice packs. This is an action that is done after the delivery of the placenta, not during. It is a comfort measure that can reduce swelling, pain, and inflammation in the perineal area.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: "Your body is responding to the events of labor, just like after a tough workout." This is an inaccurate statement that does not explain the cause of the contractions or reassure the client.
Choice B Reason: "This could be a sign that your body is trying to get rid of retained placental fragments." This is an alarming statement that may scare the client and imply that something is wrong. Retained placental fragments are rare and usually cause heavy bleeding, fever, and infection.
Choice C Reason: "Let me check your vaginal discharge just to make sure everything is fine." This is an unnecessary statement that does not answer the client's question or provide any information.
Choice D Reason:"The baby's sucking releases oxytocin which causes your uterus to contract." This is a correct statement that explains the physiological mechanism of the contractions and reassures the client that they are normal and beneficial.
Correct Answer is D
Explanation
Choice A Reason: Daily weight. This is an incorrect answer that indicates a valid parameter to assess hydration status. Daily weight is a measure of the body mass that can reflect changes in fluid balance. Daily weight can help detect fluid loss or gain in premature infants, who are more prone to dehydration or overhydration due to immature renal function and high insensible water loss.
Choice B Reason: Consistency of stool. This is an incorrect answer that indicates a valid parameter to assess hydration status. Consistency of stool is a measure of the texture and form of feces that can reflect changes in fluid intake and absorption. Consistency of stool can help identify diarrhea or constipation in premature infants, who are more susceptible to gastrointestinal problems such as necrotizing enterocolitis or feeding intolerance.
Choice C Reason: Volume of urine output. This is an incorrect answer that indicates a valid parameter to assess hydration status. Volume of urine output is a measure of the amount of urine produced and excreted by the kidneys that can reflect changes in fluid balance and renal function. Volume of urine output can help monitor hydration status and kidney function in premature infants, who are more vulnerable to fluid overload or deficit and renal impairment.
Choice D Reason: Blood pH. This is because blood pH is a measure of the acidity or alkalinity of the blood, which reflects the balance between carbon dioxide and bicarbonate in the body. Blood pH is not a direct indicator of hydration status, which refers to the amount of water and electrolytes in the body. Hydration status can affect blood pH, but blood pH can also be influenced by other factors such as respiratory or metabolic disorders.

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