The nurse is providing postpartum care to a patient 24 hours after a vaginal delivery. Which action does the nurse perform prior to assessing the patient’s uterus?

Place the patient on the left side.

Assess the passage of lochia.

Ask the patient to void.

Administer a dose of oxytocin

Answer and Explanation

The Correct Answer is C

The correct answer is choice C. Ask the patient to void. This is because a full bladder can displace the uterus and interfere with its contraction, which can lead to postpartum hemorrhage The nurse should assess the patient’s uterus after ensuring that the bladder is empty.

Choice A is wrong because placing the patient on the left side does not affect the uterus assessment. It may help with blood circulation and oxygenation, but it is not necessary before checking the uterus.

Choice B is wrong because assessing the passage of lochia is part of the uterus assessment, not a prerequisite. Lochia is the vaginal discharge after giving birth, containing blood, mucus, and uterine tissue It has three stages: lochia rubra (red), lochia serosa (pinkish brown), and lochia alba (yellowish white)

Choice D is wrong because administering a dose of oxytocin is not required before assessing the uterus.

Oxytocin is a hormone that stimulates uterine contractions and reduces bleeding. It may be given during or after labor to prevent or treat postpartum hemorrhage, but it is not a routine procedure.

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Correct Answer is B

Explanation

A client who had a vertical incision on her uterus but a low transverse incision on her skin for her previous cesarean delivery has the highest risk of uterine rupture during labor.This is because a vertical incision on the uterus weakens the uterine wall and increases the risk of rupture during contractions.

Normal ranges for uterine rupture during labor are 0.2% to 1.5% for women who have had one previous cesarean delivery with a low transverse incision and 0.9% to 3.7% for women who have had two or more previous cesarean deliveries with low transverse incisions.

A. Advanced maternal age B. Full-term gestation C. Absence of medical or obstetric complications D. Lack of uterine contractions before 37 weeks of gestation

Correct Answer is A

Explanation

Advanced maternal age is a risk factor for preterm labor, which occurs when regular contractions begin to open the cervix before 37 weeks of pregnancy.

Preterm labor can lead to premature birth, which can have serious health consequences for the baby.

Choice B is wrong because full-term gestation is not a risk factor for preterm labor.Full-term gestation means that the pregnancy lasts between 39 and 40 weeks, which is the ideal duration for the baby’s development.

Choice C is wrong because absence of medical or obstetric complications is not a risk factor for preterm labor.Some medical or obstetric complications that can increase the risk of preterm labor include urinary tract infections, high blood pressure, bleeding from the vagina, placenta previa, diabetes and blood clotting problems.

Choice D is wrong because lack of uterine contractions before 37 weeks of gestation is not a risk factor for preterm labor.Uterine contractions are a sign of preterm labor, not a cause of it.

Some other risk factors for preterm labor that the nurse should include in the discussion are:

• Previous preterm delivery or preterm labor

• Multiple gestation (twins, triplets or more)

• Abnormalities of the reproductive organs, such as a short cervix

• Ethnicity (African American and American Indian/Alaska Native mothers have higher rates of preterm birth than white mothers)

• Age of the mother (women younger than 18 are more likely to have a preterm delivery)

• Tobacco use and substance abuse

• Short time period between pregnancies (less than 18 months)

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The nurse is providing postpartum care to a patient 24 hours after a vaginal delivery. Which action does the nurse perform prior to assessing the patient’s uterus?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medical records of four clients who are pregnant and planning to have a vaginal birth after cesarean (VBAC). Which of the following clients has the highest risk of uterine rupture during labor?

Correct Answer is B

Explanation

A client is concerned about the risk factors for pre-term labor. Which of the following factors should the nurse include in the discussion?

Correct Answer is A

Explanation

A nurse is evaluating the effectiveness of antenatal education on a group of expectant mothers. Which of the following outcomes would indicate a positive effect of the education?

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A nurse is reviewing the laboratory results of a postpartum client who had a hemorrhage due to uterine atony. Which finding would be expected in this client?

A nurse is caring for a client who is in the informal stage of maternal role attainment. Which of the following statements by the client indicates an understanding of this stage?

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