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The laboring person is in pain and very anxious. They do not want to use traditional pain relief methods. What can the nurse offer the laboring person to help with relaxation and reducing anxiety?
- A. lavender oil
- B. epidural
- C. nalbuphine hydrochloride (Nubain)
- D. cold rag
Correct Answer: A
Rationale: The correct answer is A: lavender oil. Lavender oil is a natural remedy known for its calming and relaxing properties, which can help reduce anxiety and promote relaxation in laboring individuals. It is safe and non-invasive, making it an ideal choice for someone who does not want traditional pain relief methods.
Incorrect choices:
B: Epidural is a commonly used pain relief method that involves injecting anesthesia into the epidural space, providing effective pain relief but not specifically targeting relaxation and anxiety reduction.
C: Nalbuphine hydrochloride (Nubain) is a synthetic opioid analgesic that can help manage pain but may not address the individual's desire for non-traditional methods.
D: Cold rag may provide some temporary relief for discomfort but may not be as effective in promoting relaxation and reducing anxiety compared to the calming effects of lavender oil.
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A patient in labor is approaching the transition stage and already has an epidural in place. An additional dose of medication has been prescribed and administered to the patient. Which priority intervention should be performed in order to evaluate the clinical response to treatment?
- A. Obtain a pain scale response from the patient based on a 0 to 10 scale.
- B. Document maternal blood pressure and fetal heart rates following medication administration and observe for any variations.
- C. Document intake and output on the electronic health record (EHR).
- D. Increase the flow rate of prescribed parenteral fluid to maintain hydration.
Correct Answer: B
Rationale: The correct answer is B. Document maternal blood pressure and fetal heart rates following medication administration and observe for any variations. This is because assessing maternal blood pressure and fetal heart rates can provide crucial information about the patient's response to the medication and the overall well-being of both the mother and the baby during labor. Any variations in these vital signs could indicate potential complications that need immediate attention.
Choice A is not the priority as pain assessment, though important, may not provide immediate information on the effectiveness of the medication in this critical stage of labor. Choice C, documenting intake and output, is not as critical as monitoring vital signs in this scenario. Choice D is also not the priority as increasing fluid rate, though important for hydration, may not be the immediate concern in evaluating the clinical response to the medication.
A patient who is receiving oxytocin (Pitocin) infusion for the augmentation of labor is
- A. Which intervention would be a priority?
- B. Increase rate of Pitocin infusion to help spread out contraction pattern.
- C. Place oxygen on patient at 8 to 10 L/minute via face mask and turn patient to left
- D. Stop Pitocin infusion.
Correct Answer: A
Rationale: The correct answer is A because the priority intervention for a patient receiving oxytocin infusion for labor augmentation is to monitor fetal heart rate and uterine contractions. This is essential to ensure the safety of both the mother and the baby. Increasing the rate of Pitocin infusion (B) can lead to hyperstimulation and fetal distress. Providing oxygen and changing position (C) may be helpful in some situations but are not the priority. Stopping the Pitocin infusion (D) should only be done if there are signs of fetal distress or other complications.
Which patient presentation is an acceptable indication for serial oxytocin induction of labor?
- A. Multiple fetuses
- B. Polyhydramnios
- C. History of long labors
- D. Past 42 weeks of gestation
Correct Answer: D
Rationale: Rationale:
1. Past 42 weeks of gestation increases the risk of stillbirth.
2. Oxytocin can help initiate labor to reduce the risk.
3. Induction at this stage is considered safe and beneficial.
4. Other choices are not direct indications for oxytocin induction and may have different management strategies.
Summary:
- A: Multiple fetuses and polyhydramnios may require different approaches.
- B: History of long labors may not necessarily indicate the need for oxytocin induction.
The laboring person wants to use open glottis breathing for pushing. How can the nurse support the person?
- A. Encourage the person to breathe however is most comfortable.
- B. Tell the person they should hold their breath for 10 counts.
- C. Explain that open glottis pushing is not effective.
- D. Discuss that the health-care provider would not allow them to use that breathing.
Correct Answer: A
Rationale: The correct answer is A because open glottis breathing is a common technique during the pushing stage of labor as it helps prevent breath-holding and excessive pressure buildup. By encouraging the person to breathe however is most comfortable, the nurse supports their autonomy and allows them to effectively engage in open glottis breathing.
Choice B is incorrect because holding the breath for counts can lead to increased intra-abdominal pressure and is not recommended during pushing. Choice C is incorrect as open glottis breathing is an effective technique for pushing. Choice D is incorrect as healthcare providers typically support the individual's chosen breathing techniques during labor.
Which comfort measure should the nurse utilize in order to enable a laboring woman to relax?
- A. Recommend frequent position changes.
- B. Palpate her filling bladder every 15 minutes.
- C. Offer warm wet cloths toN useR on Ithe GpatiBen.t'Cs faMce and neck. U S N T O
- D. Keep the room lights lit so the patient and her coach can see everything.
Correct Answer: C
Rationale: The correct answer is C because offering warm wet cloths to place on the patient's face and neck can help promote relaxation by providing a soothing sensation. This measure can help to reduce stress and tension, creating a calming environment for the laboring woman.
A: Recommending frequent position changes can help with labor progress and comfort, but it may not specifically address relaxation.
B: Palpating the filling bladder every 15 minutes is important for monitoring urinary output, but it is not a direct comfort measure for relaxation.
D: Keeping the room lights lit may be necessary for visibility, but bright lights can be distracting and may hinder relaxation.