Author Question: The nurse is caring for a client in the fourth stage of labor. Which assessment findings should the ... (Read 45 times)

shofmannx20 · **on:** Jun 28, 2018

The nurse is caring for a client in the fourth stage of labor. Which assessment findings should the nurse identify as a potential complication? (Select all that apply.)

a. Soft boggy uterus
b. Maternal temperature of 99 F
c. High uterine fundus displaced to the right
d. Intense vaginal pain unrelieved by analgesics
e. Half of a lochia pad saturated in the first hour after birth

Question 2

Which interventions are required following an amniotomy procedure? (Select all that apply.)

a. Notation related to amount of fluid expelled
b. Color and consistency of fluid
c. Fetal heart rate
d. Maternal blood pressure
e. Maternal heart rate

kingdude89 · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: A, C, D
Assessment findings that may indicate a potential complication in the fourth stage include a soft boggy uterus, high uterine fundus displaced to the right, and intense vaginal pain unrelieved by analgesics. The maternal temperature may be slightly elevated after birth because of the inflammation to tissues, and half of a lochia pad saturated in the first hour after birth is within expected amounts.

Answer to Question 2

ANS: A, B, C
Following amniotomy (AROM), observation and documentation of the amount of fluid, color and consistency, and fetal heart rate should be done. Maternal assessments related to blood pressure and heart rate are not required.