During a postpartum assessment on a client who delivered vaginally, the nurse would complete which of the following actions? (Select all that apply.)

Correct Answer: B

Rationale: Auscultating the carotid artery is a crucial step in postpartum assessment as it helps to monitor the client's cardiovascular status, especially during the immediate postpartum period when there is an increased risk of hemorrhage. By listening for any abnormal sounds or changes in the pulse, the nurse can quickly identify and intervene in case of any cardiovascular complications. Palpating the breasts is also an essential part of postpartum assessment, as it allows the nurse to check for engorgement, tenderness, or signs of infection. This step is important for assessing the client's breastfeeding experience and providing support and education as needed. However, this action alone does not address the immediate cardiovascular concerns that arise during the postpartum period. Checking vaginal discharge is another important aspect of postpartum assessment, as it helps the nurse monitor for signs of infection, hemorrhage, or other complications related to the delivery. By assessing the color, amount, and odor of the discharge, the nurse can identify any abnormalities and provide appropriate care. However, this step does not directly address the cardiovascular status of the client, which is crucial in the immediate postpartum period. Inspecting the perineum is also a key component of postpartum assessment, as it allows the nurse to assess for any tears, lacerations, or signs of infection that may have occurred during delivery. By checking the perineum, the nurse can provide proper wound care and prevent complications. While this step is important for the client's physical recovery, it does not directly address the cardiovascular status that needs to be monitored closely during the immediate postpartum period. In conclusion, auscultating the carotid artery is the correct action to include in a postpartum assessment on a client who delivered vaginally because it directly addresses the cardiovascular status, which is crucial in the immediate postpartum period. Palpating the breasts, checking vaginal discharge, and inspecting the perineum are also important steps in postpartum assessment but do not directly address the immediate cardiovascular concerns that need to be monitored closely.

Correct Answer: A

Rationale: Periodic breathing is the correct answer in this scenario. Periodic breathing is a normal respiratory pattern in premature infants where they have short episodes of apnea followed by rapid breathing. In this case, the infant stopping breathing for 20-30 seconds then resuming breathing aligns with the definition of periodic breathing. This pattern is commonly seen in premature infants and usually resolves on its own as the infant matures. Apneic breathing (choice B) refers to a more prolonged cessation of breathing and is not characteristic of the brief episodes seen in periodic breathing. Apneic breathing is a cause for concern and may require intervention to support the infant's breathing. Grunting (choice C) is a sound made by infants during expiration to help keep the lungs inflated. While grunting may be present in infants with respiratory distress syndrome, it does not describe the pattern of breathing observed in this case. Neonatal dyspnea (choice D) refers to difficulty breathing in a newborn, which can present with a variety of symptoms such as grunting, nasal flaring, and retractions. While respiratory distress syndrome can lead to neonatal dyspnea, the specific breathing pattern described in the question is better classified as periodic breathing.

Correct Answer: C

Rationale: The correct answer is C: When the fetus is acidotic. When the fetus is acidotic, it means that there is an imbalance in the pH levels in the blood, indicating potential distress or hypoxia. This can lead to changes in the fetal heart rate and variability, which would be reflected on the monitor tracing. Acidosis can occur when the fetus is not receiving enough oxygen, which can happen during labor if there are issues with placental perfusion or if there is compression of the umbilical cord. Choice A, during fetal movement, is not necessarily when the nurse would expect to see fetal heart changes on the monitor tracing. Fetal movement can cause temporary fluctuations in the heart rate, but these changes should not be sustained or significant unless there is an underlying issue. Choice B, after the administration of analgesics, would not typically cause fetal heart changes on the monitor tracing. Analgesics may affect the mother's heart rate or blood pressure, but they should not directly impact the fetus unless there are complications. Choice D, with poor placental perfusion, is a common cause of fetal distress but may not always result in immediate changes on the monitor tracing. Poor placental perfusion can lead to decreased oxygen and nutrients reaching the fetus, which can eventually lead to acidosis and changes in the fetal heart rate, but this process may take some time to manifest on the monitor tracing.

Correct Answer: D

Rationale: During the second stage of labor, the cervix is fully dilated, and the woman is ready to push the baby out. Option D, taking a slow cleansing breath before bearing down, is the correct choice because it helps the woman gather energy and focus before pushing. This breath helps prevent hyperventilation and provides the woman with the necessary oxygen to push effectively. Option A, holding her breath for twenty seconds during every contraction, is incorrect because holding the breath for too long can decrease oxygen levels to the baby and increase the woman's risk of hyperventilation and dizziness. This can lead to decreased effectiveness in pushing and potential harm to both the mother and the baby. Option B, blowing out forcefully during every contraction, is also incorrect because blowing out forcefully may reduce the woman's ability to push effectively. It can also cause the woman to waste energy and may not provide the necessary force to move the baby down the birth canal. Option C, pushing between contractions until the fetal head is visible, is incorrect because pushing between contractions can lead to exhaustion and may not be as effective as pushing during contractions. It is important for the woman to conserve energy and push during contractions when the uterus is actively working to move the baby down.

Correct Answer: B

Rationale: During the third stage of labor, the correct chronological order of physiological changes is as follows: B: Membranes separate from the uterine wall - This is the correct answer because during the third stage of labor, the placenta detaches from the uterine wall, and the amniotic sac is expelled. Now, let's discuss why the other choices are incorrect: A: Hematoma forms behind the placenta - This choice is incorrect because the formation of a hematoma typically occurs due to trauma or injury and is not a normal physiological change during the third stage of labor. C: The uterus contracts firmly - This choice is incorrect because uterine contractions typically occur during the first and second stages of labor to help push the baby out. In the third stage, the focus is on delivering the placenta, not on uterine contractions. D: The uterine surface area dramatically decreases - This choice is incorrect because the uterus does not decrease in size during the third stage of labor. After the delivery of the placenta, the uterus will continue to contract to help control bleeding and return to its pre-pregnancy size over time.