The nurse is creating a care plan for an intrapartum client at the end of the third stage of labor.
What is the desired outcome for the client.
Firmly contracted uterine fundus.
Efficient fetal heart beat variability.
Absence of discomfort.
Maternal respiratory rate within expected range.
The Correct Answer is A
Choice A rationale
The third stage of labor is the time from the birth of the baby until the placenta is expelled. Following placental expulsion, the uterus must contract firmly (like a grapefruit or softball) to clamp down on the open blood vessels at the site where the placenta was attached. This firm contraction is crucial to prevent excessive postpartum hemorrhage.
Choice B rationale
Fetal heart rate variability (fluctuations in the FHR baseline) is an indicator of a healthy fetal nervous system and oxygenation and is a focus of the first and second stages of labor. After the baby is born (end of the third stage), fetal monitoring is no longer relevant; the maternal state and uterine involution are the priorities.
Choice C rationale
While comfort is important throughout labor and post-delivery, the desired physiological outcome at the end of the third stage is focused on preventing hemorrhage. Some discomfort is expected due to uterine contractions ("afterpains") and is an indicator of the desired uterine contraction necessary for hemostasis.
Choice D rationale
A maternal respiratory rate within the expected range (12 to 20 breaths per minute) is a general goal throughout labor. However, the most critical and unique outcome specific to the end of the third stage is the firm uterine contraction to achieve hemostasis and prevent the life-threatening complication of postpartum hemorrhage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Knowing when contractions began is important for assessing the progression and duration of labor and determining the phase of labor the client is in. However, when birth is imminent, this information is secondary to assessing the integrity of the amniotic sac. Immediate risk assessment for the baby is the top priority for imminent delivery.
Choice B rationale
The estimated due date (EDD) is vital for determining fetal maturity and potential risks associated with prematurity or post-term gestation. While essential data, the EDD does not address the immediate safety and delivery logistics when birth is imminent. The most urgent question relates to current membrane status and imminent delivery risk.
Choice C rationale
Ascertaining if the membranes have ruptured is the most crucial question when delivery is imminent because it directly relates to immediate fetal risk and delivery preparation. Ruptured membranes with a presenting part not engaged increases the risk of umbilical cord prolapse, a true obstetric emergency, and also requires urgent sterile assessment and documentation of the fluid's color and time of rupture.
Choice D rationale
Parity (whether this is the first pregnancy) is significant as multiparas (those with previous pregnancies) often have faster labors and deliveries due to a more compliant cervix and uterus. While informative for estimating delivery speed, it is less critical than establishing the immediate status of the amniotic fluid and cord to ensure a safe, planned delivery.
Correct Answer is B
Explanation
Choice A rationale
Indeterminate is a term primarily used to classify Fetal Heart Rate (FHR) tracings that fall into Category II, meaning they do not meet the criteria for Category I (normal) or Category III (abnormal). This term is not used to document uterine contraction frequency or intensity. Uterine activity is typically quantified by the number of contractions in a 10-minute window, averaged over 30 minutes, or by intensity..
Choice B rationale
Tachysystole is defined as having more than five contractions in 10 minutes, averaged over a 30-minute window. This can lead to decreased fetal oxygen supply due to inadequate uterine resting time, causing fetal hypoxemia. By counting the contractions in a typical 10-minute segment on the provided tracing, there are only about 3 or 4 contractions, which is not tachysystole..
Choice C rationale
Normal uterine activity is defined as five or fewer contractions in 10 minutes, averaged over a 30-minute window. By observing the lower tracing (uterine activity/UA), there are 3 to 4 contractions within a typical 10-minute segment. This falls within the expected range for a laboring client. The contractions are spaced appropriately, allowing for adequate uterine resting tone and placental perfusion..
Choice D rationale
Bradycardia is a term used to describe a slow Fetal Heart Rate (FHR), specifically a baseline FHR less than 110 beats per minute (bpm). This is a measure of the fetus's heart rate, not a descriptor for uterine contraction frequency or pattern. The uterine activity is described by frequency, duration, and intensity, not heart rhythm terms like bradycardia.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.