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What is the recommended method of pain relief during labor for a woman who wants to avoid medication and prefers non-pharmacologic interventions?
- A. Nitrous oxide
- B. Intramuscular opioids
- C. Transcutaneous electrical nerve stimulation (TENS)
- D. All of the above
Correct Answer: C
Rationale: TENS is a non-pharmacologic method of pain relief that allows the woman to avoid medication.
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Which of the following actions should the nurse plan to implement? For each potential nursing action, click to specify if the intervention is indicated or contraindicated for the newborn.
- A. Educate the parents to begin range of motion exercises on the affected arm after 1 week.
- B. Assess for grasp reflex in the affected extremity.
- C. Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt.
- D. Instruct parents to limit physical handling for 2 weeks.
Correct Answer:
Rationale: Educate the parents to begin range of motion exercises on the affected arm after 1 week is indicated. Passive ROM exercises of the arm are indicated to restore function of the extremity. The initiation of these exercises is delayed for approximately 1 week to prevent additional injury to the brachial plexus. Assess for grasp reflex in the affected extremity is indicated. With Erb-Duchenne paralysis, only the upper arm is affected. The function of the wrists and fingers should be unaffected; the nurse should assess for a palmar grasp reflex.Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt is indicated. Intermittent immobilization of the affected arm across the newborn's abdomen can be achieved by pinning the sleeve to the shirt.Instruct parents to limit physical handling for 2 weeks is contraindicated. Parents and guardians should participate in the physical care of their newborn to increase parental-infant attachment. Providing education and practice opportunities for the parents will decrease their fears of injuring the newborn and increase confidence and bonding.
What is the recommended method of pain relief during labor for a woman who wants to avoid medication?
- A. Breathing techniques
- B. Massage
- C. Water immersion
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D: All of the above. Breathing techniques help manage pain by promoting relaxation and reducing stress. Massage can provide comfort and help relieve muscle tension. Water immersion, such as a warm bath or shower, can ease contractions and promote relaxation. Choosing all options provides a comprehensive approach to pain relief during labor without medication. Options A, B, and C individually offer effective non-pharmacological methods, but using them in combination (D) offers a more holistic and effective pain management strategy.
Which of the following is a potential complication of maternal hypertension during pregnancy?
- A. Placental abruption
- B. Fetal growth restriction
- C. Preterm labor
- D. All of the above
Correct Answer: D
Rationale: Maternal hypertension can lead to placental abruption, fetal growth restriction, and preterm labor.
A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication? (Select all that apply.)
- A. Flaccid uterus
- B. Cervical laceration
- C. Excess vaginal bleeding
- D. Increased afterbirth cramping
Correct Answer: A,C
Rationale: The correct answers are A and C. A flaccid uterus indicates poor uterine tone, which can lead to postpartum hemorrhage. Oxytocin is given to enhance uterine contractions and tone, helping prevent excessive bleeding. Excess vaginal bleeding is also an indication for oxytocin administration as it can help control bleeding by promoting uterine contractions. Choices B, D, and other options are incorrect as they do not directly relate to the need for oxytocin administration in this scenario. Cervical laceration and increased afterbirth cramping may require other interventions, but they do not specifically indicate the need for oxytocin administration to address postpartum bleeding.
A nurse is caring for a client who is in labor and notes that the umbilical cord is prolapsed. Which of the following actions should the nurse take?
- A. Evaluate uterine tone.
- B. Loosely wrap the cord with petroleum gauze.
- C. Apply fundal pressure.
- D. Place the client in Trendelenburg position
Correct Answer: D
Rationale: Placing the client in the Trendelenburg position helps reduce pressure on the prolapsed cord, preventing fetal distress. Other actions like applying fundal pressure or wrapping the cord are not appropriate.