After teaching a pregnant woman who is in labor about the purpose of the
episiotomy, which of the following purposes stated by the client would indicate to the
nurse that the teaching was effective?
a. Shortens the second stage of labor
b. Enlarges the pelvic inlet
c. Prevents perineal edema
d. Ensures quick placenta delivery
✓ ~~~ a. Shortens the second stage of labor
A woman delivered a 7 lb boy spontaneous vaginal delivery 30 minutes ago. Her
fundus is firm at the umbilicus and she has moderate lochia rubra with a steady
trickle of blood noted from the vagina. The nurse determines that which assessment
finding needs to follow up?
a. Moderate lochia rubra
b. Steafy trickle of blood
c. Fundus at the umbilical level
d. Firm fundus
✓ ~~~ b. Steafy trickle of blood
,The multigravida mother with a history of rapid labor who us in active labor calls out
to the nurse, "The baby is coming!" which of the following would be the nurse's first
action?
a. Inspect the perineum
b. Time the contractions
c. Auscultate the fetal heart rate
d. Contact the birth attendant
✓ ~~~ a. Inspect the perineum
A primigravid client in a Preparation for Parenting class asks how much blood is lost
during an uncomplicated delivery. The nurse should tell the woman:
a. "The maximum blood loss considered within normal limits is 500 mL."
b. "The minimum blood loss considered within normal limits is 1,000 mL."
c. "Blood loss during a delivery is rarely estimated unless there is a hemorrhage."
d. "It would be very unusual if you lost more than 100 mL of blood during the
delivery."
✓ ~~~ a. "The maximum blood loss considered within normal limits is 500 mL."
Which of the following statements by a primigravid client about the amniotic fluid and
sac indicates the need for further teaching?
a. "The amniotic fluid helps to dilate the cervix once labor begins."
b. "Fetal nutrients are provided by the amniotic fluid."
, c. "Amniotic fluid provides a cushion against impact of the maternal abdomen."
d. "The fetus is kept at a stable temperature by the amniotic fluid and sac."
✓ ~~~ b. "Fetal nutrients are provided by the amniotic fluid."
During a childbirth preparation class, a primigravid client at 36 weeks' gestation tells
the nurse, "My lower back has really been bothering me lately." Which of the
following exercises suggested by the nurse would be most helpful?
a. Pelvic rocking.
b. Deep breathing.
c. Tailor sitting.
d. Squatting
✓ ~~~ a. Pelvic rocking.
A woman delivered a 7 lb boy spontaneous vaginal delivery 30 minutes ago. Her
fundus is firm at the umbilicus and she has moderate lochia rubra. Which nursing
diagnosis is highest priority as the nurse plan care?
a. Risk for infection related to episiotomy
b. Constipation related to fear of pain
c. Potential for impaired urinary elimination related to perennial edema
d. Deficient knowledge related to lack of knowledge regarding newborn care
✓ ~~~ c. Potential for impaired urinary elimination related to perennial edema
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