During the fourth stage of labor, a client's blood pressure is ...

[dmcintosh]

During the fourth stage of labor, a client's blood pressure is 110/60 mmHg, pulse 90, and the fundus is firm, midline and halfway between the symphysis pubis and the umbilicus. Based on this data, which is the primary action by the nurse?
 
  A) Massage the fundus.
  B) Turn the client onto the left side.
  C) Place the bed in the Trendelenburg position.
  D) Continue to monitor.

Question 2

An adolescent client with fetal alcohol syndrome was arrested for assaulting another teenager after being distracted and missing the school bus. Which is the most likely reason for the adolescent's behavior?
 
  A) Dislike of the other teenager.
  B) Fetal alcohol syndrome.
  C) Fetal alcohol syndrome and an environmental stressor.
  D) Anger over being distracted.

[joechoochoy]

Answer to Question 1

Answer: D

The client's assessment data are normal for the fourth stage of labor, so monitoring is the only action necessary. During the fourth stage of labor, the mother experiences a slight drop in blood pressure and a slightly increased pulse. A left lateral position is not necessary with a BP of 110/60 and a pulse of 90. The Trendelenburg position is not necessary with a BP of 110/60 and a pulse of 90. The uterus should be midline and firm; massage is not necessary.

Answer to Question 2

Answer: C

Early brain injury, as with prenatal alcohol exposure, is a risk factor in aggression but is not enough by itself. When the injury is combined with other genetic factors and environmental stressors, impulsiveness and aggression may be triggered. The client's outburst was most likely due to the fetal alcohol syndrome and an environmental stressor. There is not enough information to determine whether the client likes or dislikes the other teenager or if the client was angry because he was distracted.