Question

A nurse is caring for a client who is in the fourth stage of labor and is receiving oxytocin via continuous IV infusion. Which of the following assessments is the nurse's priority? A. Amount of vaginal bleeding B. Amount of urinary output C. Pain level D. Fundal height

Answer 1

The priority assessment for a nurse caring for a client in the fourth stage of labor and receiving oxytocin is the amount of vaginal bleeding to quickly identify and manage potential postpartum hemorrhage.

Step-by-step explanation:

The student asked which assessment is the nurse's priority for a client in the fourth stage of labor and receiving oxytocin via continuous IV infusion. Priority should be given to assessing the amount of vaginal bleeding. This is because after the delivery of the placenta, the fourth stage of labor, also known as the recovery stage, includes close monitoring for hemorrhage. Postpartum hemorrhage is one of the leading causes of maternal mortality, and excessive vaginal bleeding can be a vital sign of this life-threatening condition. Other assessments such as urinary output, pain level, and fundal height are also important but secondary to the immediate identification and management of hemorrhage.

Answer 2

The priority for the nurse in the fourth stage of labor with a client receiving oxytocin is to monitor the amount of vaginal bleeding to prevent postpartum hemorrhage. So the correct option is A.

Step-by-step explanation:

The nurse's priority when caring for a client who is in the fourth stage of labor and receiving oxytocin via continuous IV infusion should be assessing the amount of vaginal bleeding. This is because following the delivery of the placenta, which marks the end of the third stage, the mother can be at risk for postpartum hemorrhage, a potentially life-threatening condition. Oxytocin is administered to promote uterine contractions, which help to minimize bleeding by compressing the blood vessels in the uterus. Thus, monitoring vaginal bleeding ensures that the uterus is contracting properly and that excessive bleeding is not occurring.