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What marks the end of the third stage of labor?
- A. Full cervical dilation
- B. Expulsion of the placenta and membranes
- C. Birth of the infant
- D. Engagement of the head
Correct Answer: B
Rationale: The third stage of labor extends from the birth of the infant until the placenta is detached and expelled.
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The nurse observes the patient bearing down with contractions and crying out, 'The baby is coming!' What is the best nursing intervention?
- A. Find the physician.
- B. Stay with the woman and use the call bell to get help.
- C. Send the woman's partner to locate a registered nurse.
- D. Assist with deep breathing to slow the labor process.
Correct Answer: B
Rationale: If birth appears to be imminent, the nurse should not leave the woman and should summon help with the call bell.
Vaginal examination reveals the presenting part is the infant's head, which is well flexed on the chest. What is this presentation?
- A. Vertex
- B. Military
- C. Brow
- D. Face
Correct Answer: A
Rationale: In the vertex presentation, the fetal head is the presenting part. The head is fully flexed on the chest.
What do late decelerations indicate?
- A. A nonreassuring pattern
- B. Uteroplacental insufficiency
- C. Fetal heart depression
- D. Cord compression
- E. Head compression
Correct Answer: A,B,C
Rationale: Late decelerations indicate a nonreassuring pattern, uteroplacental insufficiency, and fetal heart depression.
The nurse formulates a nursing diagnosis for a woman in the fourth stage of labor. What is the most appropriate nursing diagnosis?
- A. Pain related to increasing frequency and intensity of contractions
- B. Fear related to the probable need for cesarean delivery
- C. Dysuria related to prolonged labor and decreased intake
- D. Risk for injury related to hemorrhage
Correct Answer: D
Rationale: In the fourth stage of labor, a priority nursing action is identifying and preventing hemorrhage.
How should the nurse intervene to relieve perineal bruising and edema following delivery?
- A. Place an ice pack on the area for 12 hours.
- B. Place a warm pack on the perineal area for 24 hours.
- C. Administer aspirin to relieve inflammation.
- D. Change the perineal pad frequently.
Correct Answer: A
Rationale: An ice pack can be placed on the mother's perineum to reduce bruising and edema for 12 hours followed by a warm pack after the first 12 to 24 hours after delivery.