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What needs to be assessed during the fourth stage of
labor? - ANSWER-the woman's vital signs, status of the
uterine fundus and perineal area, comfort level, lochia
amount, and bladder status
How often are vital signs taken during the 4th stage of
labor? - ANSWER-q15 min for first hour, q30 for next hour.
Using a diagram, the nurse demonstrates the sequence of
the mechanisms of labor. Place the seven mechanisms of
labor in sequential order. Put a comma and space
between each answer choice (a, b, c, d, etc.)
,a. Extension
b. Engagement
c. Descent
d. Flexion
e. Expulsion
f. Internal rotation
g. External rotation - ANSWER-Answer: C, B, D, F, A, G, E
Rationale: The process by which a normal vaginal delivery
is accomplished requires the infant to make the descent
into the birth canal, engage, flex and internally rotate, and
extend and externally rotate to be expelled.
Monitoring vital signs and fundal and lochia status every
15 minutes and documenting them
,Assessing for postpartum hemorrhage and urinary
retention via uterine palpation
Promoting comfort by offering analgesia for afterpains and
warm blankets to reduce chilling
Offering fluids and nourishment if desired
Encouraging parent-infant attachment by providing privacy
for the family
Being knowledgeable about and sensitive to typical
cultural practices after birth
Assisting and encouraging the mother to nurse, if she
chooses, during the recovery period to promote uterine
firmness (the release of oxytocin from the posterior
pituitary gland stimulates uterine contractions)
, Teaching the woman how to assess her fundus for
firmness periodically and to massage it if it is boggy
Describing the lochia flow and normal parameters to
observe for postpartum
Teaching safety techniques to prevent newborn abduction
Demonstrating the use of the portable sitz bath as a
comfort measure for her perineum if she had a laceration
or an episiotomy repair
Explaining comfort and hygiene measures and when to
use them
Assisting with ambulation when getting out of bed for the
first time
Providing information about the routine on the mother-
baby unit or nursery duri