Health Promotion and Maintenance
62. A client has just completed the second stage of labor and has begun the third stage of labor. Which nursing action has priority at this time?
Health Promotion and Maintenance
62. A client has just completed the second stage of labor and has begun the third stage of labor. Which nursing action has priority at this time?
. Promotion of the bonding process.
. Administration of an oxytocic medication.
. Encouraging the client to push.
. Physical assessment of the neonate.
Test-Taking Tip
The key to this question is the wording, "has begun the third stage of labor," the delivery of the placenta. Once the placenta has delivered, the client would be in the fourth stage of labor.
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Analysis; Cognitive Level: Analysis; Client Need/Subneed: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
Health Promotion and Maintenance
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Answer 1 is incorrect because promoting the bonding process as soon as possible after birth is important, but the evaluation of the newborn's physical stability is most important at this time. Answer 2 is incorrect because oxytocin should not be administered until after the placenta is delivered, which usually occurs within 30 minutes after delivery of the infant. Answer 3 is incorrect because the third stage of labor is the stage of delivery of the placenta. The placenta will spontaneously separate from the uterine wall and be expelled by uterine contractions. Maternal pushing is not needed. Answer 4 is correct because the client has just delivered; the placenta has not delivered yet. The newborn's physical condition and Apgar scoring is a priority at 1 and 5 minutes after delivery.