Nokea
The nurse is caring for a patient in transition. Which sign is most indicative that this phase of labor is occurring?
- A. Regular contractions every 3 minutes lasting 60 seconds.
- B. Increased bloody show and complaints of pressure.
- C. The urge to push with each contraction.
- D. Cervical dilation of 4 to 5 cm.
Correct Answer: B
Rationale: The correct answer is B because increased bloody show and complaints of pressure are indicative of the transition phase of labor. This phase occurs when the cervix dilates from 8 to 10 cm and contractions are strong and close together. This is a sign that the baby is moving down the birth canal. The other choices are incorrect because A describes the active phase of labor, C indicates the second stage of labor, and D reflects early labor. B is the most appropriate choice as it specifically aligns with the characteristics of the transition phase.
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Which assessment finding is an indication of hemorrhage in the recently delivered postpartum patient?
- A. Elevated pulse rate
- B. Elevated blood pressure
- C. Firm fundus at the midline
- D. Saturation of two perineal pads in 4 hours
Correct Answer: D
Rationale: The correct answer is D. Saturation of two perineal pads in 4 hours is an indication of hemorrhage postpartum. This is because excessive bleeding after delivery can lead to soaking through pads quickly. A: Elevated pulse rate can be a sign of shock but not specific to hemorrhage. B: Elevated blood pressure is not a typical sign of hemorrhage. C: A firm fundus at the midline is a normal finding postpartum and not indicative of hemorrhage.
A woman who is gravida 3, para 2 enters the intrapartum unit. The most important nursing assessments include
- A. contraction pattern, amount of discomfort, and pregnancy history.
- B. fetal heart rate, maternal vital signs, and the woman's nearness to birth.
- C. last food intake, when labor began, and cultural practices the couple desires.
- D. identification of ruptured membranes, the woman's gravida and para, and access to a support person.
Correct Answer: B
Rationale: The correct answer is B because fetal heart rate, maternal vital signs, and the woman's nearness to birth are crucial assessments in the intrapartum period. Fetal heart rate indicates fetal well-being, maternal vital signs reflect maternal status, and assessing the nearness to birth helps in determining the stage of labor and necessary interventions.
A is incorrect because while contraction pattern and discomfort are important, pregnancy history is not as immediate a concern in the intrapartum period.
C is incorrect as last food intake and cultural practices are not the most critical assessments during labor.
D is incorrect because while identification of ruptured membranes is important, the woman's gravida and para are less immediate concerns compared to fetal heart rate and maternal vital signs.
A nurse is assisting a laboring patient with breathing techniques to reduce labor pain. Which technique involves exhaling slowly while concentrating on relaxing each muscle group?
- A. Cleansing breaths
- B. Slow-paced breathing
- C. Modified-paced breathing
- D. Effleurage
Correct Answer: B
Rationale: The correct answer is B: Slow-paced breathing. This technique involves exhaling slowly while focusing on relaxing each muscle group, which helps reduce labor pain. Slow-paced breathing promotes relaxation and reduces stress, making it an effective pain management technique during labor. Cleansing breaths (A) focus on deep breathing to clear the mind, not necessarily on muscle relaxation. Modified-paced breathing (C) involves breathing in a controlled pattern but may not specifically target muscle relaxation. Effleurage (D) is a massage technique involving light stroking movements, not breathing techniques for pain management.
What does the nurse explain to the laboring person and partner about nitrous oxide?
- A. It makes the newborn have respiratory depression.
- B. It causes the laboring person to have decreased respirations.
- C. It does not affect respiration as an opiate would.
- D. The mask is held to the person's face by the partner.
Correct Answer: C
Rationale: The correct answer is C because nitrous oxide does not affect respiration like an opiate would. Nitrous oxide is a safe option for pain relief during labor because it does not depress the respiratory system. It is self-administered by the laboring person and does not require assistance from the partner. Choices A and B are incorrect because nitrous oxide does not cause respiratory depression in the newborn or the laboring person. Choice D is incorrect because the laboring person holds the mask to their face themselves.
The nurse is preparing a patient for a cesarean birth scheduled to be performed under general anesthesia. Which should the nurse plan to administer, if ordered by the health care provider, to prevent aspiration of gastric contents?
- A. Citric acid (Bicitra)
- B. Ranitidine (Zantac)
- C. Hydroxyzine (Vistaril)
- D. Glycopyrrolate (Robinul)
Correct Answer: C
Rationale: The correct answer is C: Hydroxyzine (Vistaril). Hydroxyzine is a first-generation antihistamine with antiemetic properties that can help reduce the risk of aspiration of gastric contents during general anesthesia. It works by decreasing nausea and vomiting, which in turn decreases the likelihood of aspiration. Citric acid (Bicitra) can actually increase gastric acidity and promote aspiration. Ranitidine (Zantac) is a histamine-2 receptor antagonist used to reduce gastric acid secretion but does not directly prevent aspiration. Glycopyrrolate (Robinul) is an anticholinergic medication used to reduce secretions but does not specifically target prevention of aspiration. Therefore, hydroxyzine is the most appropriate choice in this scenario.