NCLEX-RN Question #429: Real Exam Question with Answer & Explanation

The correct answer is D. Character of the fundus. The length of labor has little bearing on the fourth stage of labor. The type of labor and delivery is (B) The type of episiotomy will affect the client's comfort level. However, the nurse's assessment and implementations center on prevention of hemorrhage during the fourth stage

Question

The nurse has been assigned a client who delivered a 6- lb, 12-oz baby boy vaginally 40 minutes ago. The initial assessment of greatest importance for this client would be:

Options

ALength of her labor
BType of episiotomy
CAmount of IV fluid to be infused
DCharacter of the fundus

Explanation

The length of labor has little bearing on the fourth stage of labor. The type of labor and delivery is (B) The type of episiotomy will affect the client's comfort level. However, the nurse's assessment and implementations center on prevention of hemorrhage during the fourth stage of labor. The amount of bleeding from the episiotomy or hematoma formation is of higher priority than the type (C) The amount of IV fluid to be infused is a nursing function to be attended to; however, it is lower in priority than determining if hemorrhaging is occurring. (D) Character of the fundus would be the priority nursing assessment because changes in uterine tone may identify possible postpartum hemorrhage.

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