Health Promotion and Maintenance
21. A client gave birth 40 minutes ago. The placenta has not yet delivered. What is the most appropriate action for an RN to take at this time?
Health Promotion and Maintenance
21. A client gave birth 40 minutes ago. The placenta has not yet delivered. What is the most appropriate action for an RN to take at this time?
. Inform the primary health-care provider.
. Apply traction to the umbilical cord.
. Prepare the client for surgery.
. Reassure the client that this is normal.
Test-Taking Tip
Know the stages and phases of labor and the expected time frame for each of these stages.
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems
Health Promotion and Maintenance
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Answer 1 is incorrect because the primary health-care provider should still be present until after the delivery of the placenta. Answer 2 is incorrect because the primary health-care provider may sometimes apply gentle tension to the cord to facilitate delivery of the placenta, but this is not the role of the RN; and traction on the cord will increase the risk of complication, such as uterine inversion. Answer 3 is correct because the client has not delivered the placenta within 40 minutes; the physician will explore the uterus and may determine that the client has a placenta accreta, which would require surgical intervention. Answer 4 is incorrect because the normal time frame for delivery of the placenta is 5 to 30 minutes. Most placentas deliver within 5 minutes, but 40 minutes is longer than the expected time frame for this stage.