Author Question: It would be most important for a nurse caring for a mother and the infant in the fourth stage of ... (Read 27 times)

jeatrice · **on:** Jun 28, 2018

It would be most important for a nurse caring for a mother and the infant in the fourth stage of labor to do which of the following?

a. Assess and massage the fundus every 15 minutes or more often if needed
b. Massage the uterus continuously
c. Administer oxytocin per protocol
d. Assess the patient for a distended bladder

Question 2

According to agency policy, the perinatal nurse provides the following intrapartal nursing care for the patient with preeclampsia:

a. Take the patient's blood pressure every 6 hours
b. Encourage the patient to rest on her back
c. Notify the physician of urine output greater than 30 mL/hr
d. Administer magnesium sulfate according to agency policy

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

Answer to Question 1

ANS: A, C, D
The fourth stage of labor immediately follows the delivery of the placenta. The nurse should be assessing the fundus every 15 minutes for position, tone, and location. The provider may order oxytocin at this stage, and the nurse should assist the woman to the bathroom if she has a distended bladder which could interfere with the contraction of the uterus.

Answer to Question 2

ANS: d
Feedback
a. The nurse is the manager of care for the woman with preeclampsia during the intrapartal period. Careful assessments are critical. The blood pressure is taken every 1 hour or more frequently according to physician orders or institutional protocol.
b. The nurse is the manager of care for the woman with preeclampsia during the intrapartal period. Careful assessments are critical. The patient should be encouraged to assume a side-lying position to enhance uterine perfusion.
c. The nurse is the manager of care for the woman with preeclampsia during the intrapartal period. Careful assessments are critical. A urine output less than 30 mL/hr is indicative of oliguria, and the physician must be notified.
d. The nurse is the manager of care for the woman with preeclampsia during the intrapartal period. Careful assessments are critical. The nurse administers medications as ordered and should adhere to hospital protocol for a magnesium sulfate infusion.