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Which action is a priority when caring for a woman during the fourth stage of labor?.

Offering fluids as indicated.

Encouraging the woman to void.

Assessing the uterine fundus.

Assisting with perineal care.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Offering fluids is important to prevent dehydration, but it’s not the priority during the fourth stage of labor.

Choice B rationale:

Encouraging the woman to void can help prevent urinary retention, but it’s not the priority.

Choice C rationale:

Assessing the uterine fundus is the priority during the fourth stage of labor. This is to ensure that the uterus is contracting and to prevent postpartum hemorrhage.

Choice D rationale:

Assisting with perineal care is important for comfort and hygiene, but it’s not the priority.

So, the correct answer is C, assessing the uterine fundus.

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Correct Answer is D

Explanation

Choice A rationale:

The face as the presenting part is not indicated by LSA. LSA stands for Left Sacrum Anterior, which indicates the baby’s position in the womb.

Choice B rationale:

The shoulder as the presenting part is not indicated by LSA. LSA refers to the baby’s position, not the presenting part.

Choice C rationale:

The occiput as the presenting part is not indicated by LSA. LSA refers to the baby’s position, not the presenting part.

Choice D rationale:

The buttocks as the presenting part is indicated by LSA. LSA (Left Sacrum Anterior) means the baby’s sacrum (buttocks) is presenting, and it is oriented to the mother’s left side and is facing forward (anterior).

A. Obtain assistance to check for a compressed umbilical cord. B. Prepare the woman for an emergency cesarean birth. C. Document the finding. D. Help the woman change positions.

Correct Answer is D

Explanation

Choice A rationale:

Checking for a compressed umbilical cord is important as it can cause fetal distress. However, it’s not the first step in response to abnormal EFM tracing.

Choice B rationale:

Preparing for an emergency cesarean birth might be necessary if the abnormality persists and indicates fetal distress. But it’s not the immediate first step.

Choice C rationale:

Documenting the finding is part of the nursing process, but immediate interventions to address the abnormality take precedence.

Choice D rationale:

Helping the woman change positions can relieve pressure on the umbilical cord, potentially resolving the abnormality. This is often the first intervention.

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Which action is a priority when caring for a woman during the fourth stage of labor?.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is reviewing the medical record of a woman in labor and notes that the fetal position is documented as LSA. The nurse interprets this information as indicating which part as the presenting part?.

Correct Answer is D

Explanation

A client is in active labor. Checking the EFM tracing, the nurse notes variables that are abnormal. What would be the nurse's first nursing intervention?

Correct Answer is D

Explanation

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