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Which stage of labor is characterized by the period between the end of the third stage and the mother's recovery from delivery?
- A. First stage
- B. Second stage
- C. Third stage
- D. Fourth stage
Correct Answer: D
Rationale: The correct answer is D: Fourth stage. The fourth stage of labor is the period immediately following the delivery of the baby and placenta, lasting up to 2 hours. This stage is crucial for monitoring the mother's vital signs and ensuring she recovers from the delivery process. It is characterized by postpartum uterine contractions, monitoring for excessive bleeding, and observing for signs of maternal complications. The first stage refers to the onset of labor until full dilation, the second stage is active labor and delivery of the baby, and the third stage is the delivery of the placenta. Therefore, the fourth stage is specifically focused on the mother's recovery from delivery, making it the correct choice.
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What is the primary hormone responsible for maintaining the endometrium during pregnancy?
- A. Progesterone
- B. Estrogen
- C. Follicle-stimulating hormone (FSH)
- D. Luteinizing hormone (LH)
Correct Answer: A
Rationale: The correct answer is A: Progesterone. Progesterone is the primary hormone responsible for maintaining the endometrium during pregnancy. It helps to thicken the endometrial lining, ensuring a suitable environment for implantation and supporting the developing embryo. Progesterone also inhibits uterine contractions, preventing premature labor. Estrogen, FSH, and LH do not play a primary role in maintaining the endometrium during pregnancy. Estrogen is involved in the initial thickening of the endometrium, while FSH and LH are primarily responsible for ovulation and follicle development.
A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching?
- A. Bleeding gums
- B. Faintness upon rising
- C. Urinary frequency
- D. Swelling of the face
Correct Answer: D
Rationale: Swelling of the face can be a sign of preeclampsia, a serious condition that requires immediate medical attention.
A nurse is providing teaching about immunizations to a client who is pregnant. Which of the following statements should the nurse include in the teaching?
- A. The immunization for varicella should be given at least 1 month prior to delivery.
- B. You can receive the rubella immunization during the third trimester of pregnancy.
- C. The hepatitis B immunization should not be obtained until after you finish breastfeeding.
- D. You can receive the immunization for influenza at any time during your pregnancy.
Correct Answer: D
Rationale: The influenza vaccine is safe and recommended during pregnancy to protect both the mother and the baby. Varicella and rubella vaccines are contraindicated during pregnancy.
Which hormone is responsible for triggering milk ejection during breastfeeding?
- A. Progesterone
- B. Estrogen
- C. Prolactin
- D. Oxytocin
Correct Answer: D
Rationale: The correct answer is D: Oxytocin. Oxytocin is responsible for triggering milk ejection during breastfeeding by causing the contraction of muscles around the milk-producing cells, facilitating the release of milk. Progesterone and estrogen are involved in preparing the body for pregnancy and maintaining the uterine lining, not milk ejection. Prolactin stimulates milk production but not milk ejection directly. Therefore, the correct choice is oxytocin as it specifically triggers the release of milk during breastfeeding.
Which of the following actions should the nurse plan to implement? For each potential nursing action, click to specify if the intervention is indicated or contraindicated for the newborn.
- A. Educate the parents to begin range of motion exercises on the affected arm after 1 week.
- B. Assess for grasp reflex in the affected extremity.
- C. Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt.
- D. Instruct parents to limit physical handling for 2 weeks.
Correct Answer:
Rationale: Educate the parents to begin range of motion exercises on the affected arm after 1 week is indicated. Passive ROM exercises of the arm are indicated to restore function of the extremity. The initiation of these exercises is delayed for approximately 1 week to prevent additional injury to the brachial plexus. Assess for grasp reflex in the affected extremity is indicated. With Erb-Duchenne paralysis, only the upper arm is affected. The function of the wrists and fingers should be unaffected; the nurse should assess for a palmar grasp reflex.Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt is indicated. Intermittent immobilization of the affected arm across the newborn's abdomen can be achieved by pinning the sleeve to the shirt.Instruct parents to limit physical handling for 2 weeks is contraindicated. Parents and guardians should participate in the physical care of their newborn to increase parental-infant attachment. Providing education and practice opportunities for the parents will decrease their fears of injuring the newborn and increase confidence and bonding.