Author Question: During the fourth stage of labor, the nurse's first priority when planning nursing interventions is ... (Read 67 times)

jayhills49 · **on:** Jun 27, 2018

During the fourth stage of labor, the nurse's first priority when planning nursing interventions is to

a. initiate breastfeeding c. observe for urinary retention
b. observe for signs of infection d. monitor for hemodynamic changes

Question 2

A nurse says to the mother of a 6-month-old infant, Does the baby sit without assistance, and is the baby crawling? Which process is the nurse using in this interaction?

1. Health promotion
2. Health maintenance
3. Disease surveillance
4. Developmental surveillance

k.lashomb · **Reply #1 on:** Jun 27, 2018

Answer to Question 1

D
Postpartal hemorrhage and latent hemodynamic effects of anesthesia are the priorities of the nurse during the fourth stage of labor. Observing for urinary retention, signs of infection, or initiating breastfeeding are not high priority at this time.

Answer to Question 2

4
Rationale:
1. While health promotion activities are related to developmental surveillance, this question is looking specifically at the milestones.
2. While health maintenance activities are related to developmental surveillance, this question is looking specifically at the milestones.
3. These questions are not classified as disease surveillance questions.
4. The question asked by the nurse is seeking information about developmental milestones; therefore, the nurse is involved in developmental surveillance.