Nokea
A labor patient has brought in a photograph of her two children and asks the nurse to place it on the wall so that she can look at it during labor contractions. This is an example of
- A. focal point.
- B. distraction.
- C. effleurag
- D. relaxation
Correct Answer: A
Rationale: The correct answer is A: focal point. Placing the photograph on the wall serves as a focal point for the laboring patient, helping her to concentrate and stay focused during contractions. By having a specific point of visual focus, the patient can channel her energy and emotions towards the photo, providing a sense of comfort and motivation. It can also serve as a source of inspiration and reminder of the joy of motherhood, which can help in managing the pain and anxiety of labor.
Summary of other choices:
B: Distraction - While the photograph may provide a distraction, the primary purpose is to serve as a focal point for the patient.
C: Effleurage - Effleurage is a massage technique used in labor, not related to placing a photograph on the wall.
D: Relaxation - While the photograph may help in relaxation indirectly by providing comfort and focus, the primary purpose is not relaxation but rather concentration and emotional support.
You may also like to solve these questions
Which physiologic effect may occur in the presence of increased maternal pain perception during labor?
- A. Increase in uterine contractions in response to catecholamine secretion
- B. Decrease in blood pressure in response to alpha receptors
- C. Decreased perfusion to the placenta in response to catecholamine secretion
- D. Increased uterine blood flow, causing increase in maternal blood pressure
Correct Answer: C
Rationale: The correct answer is C. Increased maternal pain perception during labor can lead to decreased perfusion to the placenta due to catecholamine secretion. When a mother experiences pain, stress hormones like catecholamines are released, causing vasoconstriction of blood vessels, including those supplying the placenta. This vasoconstriction reduces blood flow to the placenta, potentially compromising fetal oxygenation and nutrient delivery.
Choice A is incorrect because increased catecholamine secretion would not directly cause an increase in uterine contractions. Choice B is incorrect because alpha receptors are not typically involved in decreasing blood pressure in response to pain perception. Choice D is incorrect because increased uterine blood flow would not cause an increase in maternal blood pressure; in fact, it would likely have the opposite effect as increased blood flow typically leads to decreased blood pressure.
If a woman's fundus is soft 30 minutes after birth, the nurse's first action should be to
- A. massage the fundus.
- B. take the blood pressure
- C. increase blood supply to the hands and feet.
- D. notify the physician or nurse-midwif
Correct Answer: A
Rationale: The correct answer is A: massage the fundus. After childbirth, a soft fundus indicates uterine atony, which can lead to postpartum hemorrhage. Massaging the fundus helps stimulate contractions and reduce bleeding, promoting uterine tone. This intervention is crucial in preventing complications. Taking blood pressure (B) is important but not the priority in this situation. Increasing blood supply to the hands and feet (C) is not relevant to addressing uterine atony. Notifying the physician or nurse-midwife (D) can be done after initiating immediate intervention to manage the soft fundus.
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.
Which intervention is an essential part of nursing care for a laboring patient?
- A. Helping the woman manage the pain
- B. Eliminating the pain associated with labor
- C. Feeling comfortable with the predictable nature of intrapartal care
- D. Sharing personal experiences regarding labor and birth to decrease her anxiety
Correct Answer: A
Rationale: The correct answer is A because helping the woman manage the pain is essential in nursing care for a laboring patient to ensure her comfort and well-being during labor. This intervention includes providing pain relief measures, such as positioning, massage, breathing techniques, and administering pain medication if needed. The focus is on supporting the woman's coping mechanisms and enhancing her overall birthing experience.
Choice B is incorrect because eliminating pain completely is not always possible or recommended in labor, as some pain is a natural part of the process. Choice C is incorrect as comfort with the predictable nature of care is not as crucial as providing active pain management. Choice D is incorrect because sharing personal experiences may not be relevant or helpful to the laboring patient and may not address her specific needs during labor.
The nurse auscultates the fetal heart rate and determines a rate of 152 bpm. Which nursing intervention is most appropriate at this time?
- A. Inform the mother that the fetal heart rate is normal.
- B. Reassess the fetal heart rate in 5 minutes because the rate is too high.
- C. Report the fetal heart rate to the physician or nurse-midwife immediately.
- D. Suggest to the mother that she is going to have a boy because the heart rate is fast.
Correct Answer: C
Rationale: The correct answer is C: Report the fetal heart rate to the physician or nurse-midwife immediately. A fetal heart rate of 152 bpm is within the normal range for a fetus, but it is essential to communicate any findings to the healthcare provider for further assessment and monitoring. This step ensures the safety and well-being of both the mother and the fetus by allowing the healthcare provider to determine if any additional actions are necessary.
Incorrect choices:
A: Inform the mother that the fetal heart rate is normal - While the heart rate may be normal, it is crucial to involve the healthcare provider for proper evaluation.
B: Reassess the fetal heart rate in 5 minutes because the rate is too high - 152 bpm is not considered too high, and immediate reporting to the healthcare provider is necessary.
D: Suggest to the mother that she is going to have a boy because the heart rate is fast - Fetal heart rate is not a reliable indicator of the baby's gender, and this