Which circumstance is most likely to cause uterine partum assessment with a woman who is 4 days atony and lead to excessive blood loss?

Correct Answer: A

Rationale: Orthostatic hypotension, which is a sudden drop in blood pressure upon standing, can result in decreased perfusion to the uterus, leading to poor contraction of the uterine muscles. This can result in uterine atony, where the uterus fails to contract properly after delivery. Uterine atony is a common cause of excessive postpartum bleeding (postpartum hemorrhage). Without proper contraction of the uterus, the blood vessels that supplied the placenta during pregnancy remain open and bleeding can continue unchecked.

Correct Answer: A

Rationale: In the scenario presented, the nurse's priority action should be to call for emergent medical assistance. A woman with a rupture during a nursing assessment could be experiencing a serious complication known as umbilical cord prolapse. This occurs when the umbilical cord slips through the cervix ahead of the baby, which can lead to compression of the cord and a serious decrease in oxygen supply to the baby. It is a medical emergency that requires immediate intervention by the healthcare team, which may include moving the mother into a knee-chest position or performing a cesarean section. Therefore, the priority action for the nurse is to ensure prompt medical intervention to protect the well-being of both the mother and the baby.

Correct Answer: A

Rationale: Suctioning the airway immediately reduces the risk of aspiration and respiratory complications.

Correct Answer: B

Rationale: Based on the information provided, the patient is experiencing regular contractions 2 minutes apart lasting 60 seconds, and she had a bloody show earlier in the morning. These signs in a multiparous patient with 6 hours of labor indicate she is most likely in the transition phase of labor. The transition phase is characterized by intense contractions that are closer together, typically 2-3 minutes apart, and lasting longer, usually around 60-90 seconds. This stage signifies the progression towards the final stages of labor, leading up to the pushing stage and delivery. Therefore, the correct answer is B, Transition phase.

Correct Answer: A

Rationale: Rh immunoglobulin prevents maternal sensitization to Rh-positive blood.