The nurse is planning care for a patient during the fourth stage of labor. Which interventions should the nurse plan to implement? (Select all that apply.)

Correct Answer: A

Rationale: The correct answer is A: Offer the patient a warm blanket. In the fourth stage of labor, the mother experiences postpartum hemorrhage risk due to uterine atony. Keeping the patient warm helps prevent hypothermia, which can lead to increased bleeding. Ice packs (B) are not indicated as they can cause vasoconstriction and inhibit proper blood flow. Massaging the uterus (C) is appropriate in the third stage of labor to prevent hemorrhage but not in the fourth stage. Delaying breastfeeding (D) is incorrect as early breastfeeding promotes uterine contractions, reducing the risk of postpartum hemorrhage.

Correct Answer: C

Rationale: The correct answer is C: Anthropoid. An anthropoid pelvis is characterized by a long and narrow shape with an anteroposterior diameter greater than the transverse diameter. This type of pelvis resembles the pelvic structure of anthropoid (higher primates) mammals. The other choices are incorrect because: A: Platypelloid pelvis is flat and broad, not long and narrow. B: Android pelvis has a heart-shaped inlet with an android appearance, not a long and narrow shape. D: Gynecoid pelvis is rounded and wider with a transverse diameter greater than the anteroposterior diameter, opposite of the described characteristics.

Correct Answer: B

Rationale: The correct answer is B: Second stage. This stage of labor is characterized by full dilation of the cervix and ends with the delivery of the baby. The intense rectal pressure reported by the patient indicates that the baby is descending through the birth canal, which is a hallmark sign of the second stage. In contrast, the first stage, latent (choice A) is characterized by early labor contractions and cervical dilation up to 6 cm. The third stage (choice C) is the delivery of the placenta, and the fourth stage (choice D) is the immediate postpartum period. The key here is recognizing the specific symptom of intense rectal pressure, which aligns with the second stage of labor.

Correct Answer: A

Rationale: The correct answer is A: Every 15 minutes. This frequency is recommended for a low-risk multiparous client in active labor without risk factors. Intermittent auscultation every 15 minutes allows for adequate monitoring of fetal well-being while also promoting maternal autonomy and mobility. Choices B, C, and D are incorrect because they are either too frequent or too infrequent for a low-risk client in active labor. Every 5 minutes (B) may be excessive and disrupt the labor process, every 20 minutes (C) may not provide sufficient monitoring, and every 30 minutes (D) may not detect changes in fetal status promptly.

Correct Answer: B

Rationale: The optimal position for a woman in the second stage of labor is lateral recumbent. This position allows gravity to aid in the descent of the baby, reduces pressure on the vena cava, and promotes better blood flow to the uterus. It also helps prevent perineal tears and facilitates fetal rotation. A: Supine position can compress the vena cava, reducing blood flow to the uterus. C: Lithotomy position is not recommended as it can lead to increased perineal trauma. D: Squatting may not be ideal as it can be tiring for the mother and may not provide optimal support for delivery.