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A laboring patient experiences a sudden rupture of membranes and the nurse observes a prolapsed cord. What is the nurse's priority action?
- A. Reposition the patient to relieve pressure on the cord.
- B. Immediately prepare the patient for a cesarean delivery.
- C. Administer oxygen at 10 L/min.
- D. Monitor the fetal heart rate continuously.
Correct Answer: A
Rationale: The correct answer is A: Reposition the patient to relieve pressure on the cord. This is the priority action because a prolapsed cord can lead to fetal compromise due to decreased blood flow. By repositioning the patient to a knee-chest or Trendelenburg position, gravity helps alleviate pressure on the cord. This action is crucial to prevent further compromise to the fetus.
Incorrect Choices:
B: Immediately prepare the patient for a cesarean delivery - While this may be necessary eventually, the immediate priority is to relieve pressure on the cord.
C: Administer oxygen at 10 L/min - Oxygen may be needed, but it is not the priority action in this emergency situation.
D: Monitor the fetal heart rate continuously - Monitoring is important, but repositioning the patient to relieve cord compression takes precedence.
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A patient presents to the labor and birth area for emergent birth. Vaginal exam reveals that the patient is fully dilated, vertex, +2 station, with ruptured membranes. The patient is extremely apprehensive because this is her first childbirth experience and asks for an epidural to be administered now. What is the priority nursing response based on this patient assessment?
- A. Use contact anesthesia for an epidural and prepare the patient per protocol.
- B. Tell the patient that she will not need any pain medication because the birth will be over in a matter of minutes and the pain will stop.
- C. Assist the patient with nonpharmacologic methods of pain distraction during this time as you prepare for vaginal birth.
- D. Call the physician for admitting orders.
Correct Answer: C
Rationale: The correct answer is C. In this scenario, the patient is fully dilated and at +2 station, indicating imminent birth. The priority nursing response should focus on assisting the patient with nonpharmacologic pain distraction methods as the birth is likely to occur soon. Nonpharmacologic pain management techniques such as breathing exercises, positioning changes, massage, and emotional support can help alleviate the patient's anxiety and provide comfort during this intense stage of labor. Administering an epidural at this late stage may not be feasible or effective due to the advanced stage of labor and imminent birth. Options A and D are not appropriate as they do not address the immediate needs of the patient in active labor. Option B is incorrect as it dismisses the patient's request for pain relief and fails to address her emotional and physical needs during labor.
The nerve block used in labor that provides anesthesia to the lower vagina and perineum is referred to as a(n)
- A. local.
- B. epidural.
- C. pudendal.
- D. spinal block.
Correct Answer: C
Rationale: The correct answer is C: pudendal. Pudendal nerve block is specifically used to provide anesthesia to the lower vagina and perineum during labor. This block targets the pudendal nerve, which innervates these areas, providing effective pain relief for childbirth.
A local anesthetic is more general and may not specifically target the lower vagina and perineum. Epidural anesthesia is typically used to provide pain relief during labor but does not specifically target the lower vagina and perineum. A spinal block provides anesthesia for a larger area including the lower abdomen and legs, not specifically the lower vagina and perineum.
The nurse receives orders for pharmacologic pain relief. What does the nurse explain to the laboring person after administering fentanyl?
- A. "I will need to monitor your oxygen saturation."
- B. "It's important for me to insert a Foley catheter."
- C. "I will need to monitor for vaginal bleeding."
- D. "It's important for me to check your cervix after I administer this medication."
Correct Answer: A
Rationale: Rationale: After administering fentanyl, the nurse explains the need to monitor oxygen saturation due to the potential respiratory depression as a side effect of the medication. This is crucial for early detection and intervention. Monitoring for vaginal bleeding (C) is unrelated to fentanyl administration. Inserting a Foley catheter (B) and checking the cervix (D) are not necessary post-fentanyl administration. Oxygen saturation monitoring is the priority for patient safety.
Which patient at term should proceed to the hospital or birth center the immediately after labor begins?
- A. Gravida 2, para 1, who lives 10 minutes away
- B. Gravida 1, para 0, who lives 40 minutes away
- C. Gravida 2, para 1, whose first labor lasted 16 hours
- D. Gravida 3, para 2, whose longest previous labor was 4 hours
Correct Answer: D
Rationale: The correct answer is D because the patient is gravida 3, para 2, with a history of the shortest previous labor of 4 hours. This indicates a high likelihood of rapid labor progression, necessitating immediate hospital or birth center access to ensure timely delivery. Choice A lives 10 minutes away, which may not be enough time in case of rapid labor. Choice B, living 40 minutes away, poses a risk of delivering en route. Choice C's previous labor duration of 16 hours suggests a longer labor, making immediate hospital arrival less critical.
Which patient will most likely have increased anxiety and tension during labor?
- A. Gravida 2 who refused any medication
- B. Gravida 2 who delivered a stillborn baby last year
- C. Gravida 1 who did not attend prepared childbirth classes
- D. Gravida 3 who has two children younger than 3 years
Correct Answer: B
Rationale: The correct answer is B. A patient who delivered a stillborn baby last year is more likely to experience increased anxiety and tension during labor due to previous traumatic experience. This can trigger fear and worry about the current pregnancy outcome, leading to heightened emotional distress.
Incorrect Choices:
A: Refusing medication does not necessarily correlate with increased anxiety during labor.
C: Not attending childbirth classes may result in lack of knowledge but does not directly relate to increased anxiety during labor.
D: Having two children younger than 3 years may cause stress but does not specifically indicate increased anxiety during labor.