QUESTION: "While waiting for the placenta to deliver, the nurse should not take any action until the nurse has done which of the following? "
CHOICES
( X ) a.) Asked the client to push down forcefully.
( X ) b.) Massaged the fundus forcefully.
( O ) c.) Observed for signs of placental separation.
( X ) d.) Reached into the uterus with sterile gloves.
RATIONALE: The best course of action is to wait for signs of placental separation, such as lengthening of the umbilical cord, a slight gush of dark blood, and a change in the contour of the fundus from discoid to globular. Pulling on the cord before the placenta is delivered may cause inversion of the uterus. After separation occurs, the client can be asked to bear down. Massaging the fundus is not helpful to ensure placental separation. Reaching into the uterus is done only when the placenta does not separate, necessitating manual removal. Doing so can lead to infection or uterine trauma. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
