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 because offering the patient a warm blanket helps prevent hypothermia, which can occur due to heat loss during the delivery process. This intervention promotes patient comfort and helps maintain their body temperature. Choice B is incorrect because placing an ice pack on the perineum is typically done in the immediate postpartum period to reduce swelling and discomfort, not during the fourth stage of labor. Choice C is incorrect because massaging the uterus if it is boggy is a postpartum intervention to prevent or treat uterine atony, not typically performed during the fourth stage of labor. Choice D is incorrect because delaying breastfeeding until the patient is rested is not necessary during the fourth stage of labor. Breastfeeding should be initiated as soon as possible after delivery to promote bonding and stimulate milk production.

Correct Answer: C

Rationale: The correct answer is C: Anthropoid. In an anthropoid pelvis, the anteroposterior diameter is greater than the transverse diameter, giving it a long and narrow shape. This type of pelvis resembles the pelvis seen in higher primates. The other choices are incorrect because: A: Platypelloid pelvis has a transversely wide and short shape. B: Android pelvis has a heart-shaped inlet with a prominent sacrum and narrow pubic arch. D: Gynecoid pelvis has a round inlet and a wide pubic arch, typically seen in females and ideal for childbirth.

Correct Answer: B

Rationale: The correct answer is B: Second stage. In the second stage of labor, the cervix is fully dilated, and the woman experiences the urge to push. The intense rectal pressure reported by the patient indicates the baby's descent into the birth canal, a characteristic of the second stage. In contrast, in the first stage (choices A and C), the cervix is still dilating, and in the fourth stage (choice D), immediate postpartum period, the focus is on maternal stabilization.

Correct Answer: A

Rationale: The correct answer is A: Every 15 minutes. During active labor, intermittent auscultation should be performed every 15 minutes for low-risk women without complications. This frequency allows for close monitoring of fetal well-being while also promoting a woman-centered approach to labor care. Choices B, C, and D are incorrect because they do not align with the standard guidelines for IA frequency during active labor. Every 5 minutes (B) is too frequent and may disrupt the woman's labor progress. Every 20 minutes (C) and every 30 minutes (D) are too far apart to ensure adequate monitoring of the fetal heart rate. Thus, choice A is the most appropriate option for this scenario.

Correct Answer: B

Rationale: The optimal position for a 28-year-old woman in the second stage of labor is the lateral recumbent position (Choice B). This position helps maximize pelvic diameter and blood flow to the uterus, facilitating labor progress. It also reduces the risk of fetal heart rate abnormalities compared to the supine position (Choice A). Lithotomy position (Choice C) can hinder the descent of the baby and increase the risk of perineal trauma. Squatting (Choice D) may be uncomfortable and less effective in promoting efficient labor progress compared to the lateral recumbent position.