During the fourth stage of labor, the client's assessment ...

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During the fourth stage of labor, the client's assessment includes a BP of 110/60, pulse 90, and the fundus is firm midline and halfway between the symphysis pubis and the umbilicus. What is the priority action of the nurse?
 
  1. Turn the client onto her left side.
  2. Place the bed in Trendelenburg position.
  3. Massage the fundus.
  4. Continue to monitor.

Question 2

Under the influence of progesterone, which of the following occur? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply.
 
  1. Temperature decreases
  2. Cervix secretes thick, viscous mucus
  3. Breasts prepare for lactation
  4. Breast glandular tissue decreases in size
  5. Vaginal epithelium proliferates

[soda0602]

Answer to Question 1

4
Explanation: 4. 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 moderate drop in both systolic and diastolic blood pressure, increased pulse pressure, and moderate tachycardia.

Answer to Question 2

2, 3, 5
Explanation: 2. Under the influence of progesterone, the cervix secretes thick, viscous mucus.
3. Under the influence of progesterone, breasts prepare for lactation.
5. Under the influence of progesterone, vaginal epithelium proliferates.

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