Maternal Monitoring During Labor ppt

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A nurse is caring for a laboring person who is in the second stage of labor. What is the most appropriate nursing intervention during the pushing phase?

  • A. assist the person into a squatting position
  • B. instruct the person to push with contractions
  • C. coach the person through controlled pushing
  • D. prepare for spontaneous delivery
Correct Answer: D

Rationale: The correct answer is D: prepare for spontaneous delivery. During the pushing phase of the second stage of labor, the most appropriate nursing intervention is to prepare for the spontaneous delivery of the baby. This involves ensuring that all necessary equipment and supplies are ready for the delivery, positioning oneself appropriately to assist with the birth, and being prepared to provide immediate care to the newborn. This intervention is crucial to ensure a safe and smooth delivery process.

Choice A (assist the person into a squatting position) may not be appropriate for all laboring individuals and may not facilitate the most effective pushing efforts. Choice B (instruct the person to push with contractions) is a general instruction that may not encompass all the necessary aspects of supporting the delivery process. Choice C (coach the person through controlled pushing) may be too restrictive and not allow for the natural progression of labor. Thus, the most appropriate intervention is to prepare for spontaneous delivery to ensure readiness and safety for both the laboring person and the newborn.

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When analyzing the need for health teaching of a prenatal multigravida, the nurse should ask which of the following questions?

  • A. What are the ages of your children?
  • B. What is your marital status?
  • C. Do you ever drink alcohol?
  • D. Do you have any allergies?
Correct Answer: C

Rationale: Asking about alcohol consumption is directly related to health teaching needs, as it can impact fetal development. The other questions, while important, are not directly related to health teaching.

A nurse is monitoring a laboring person's vital signs during the first stage of labor. Which vital sign change is most likely to indicate the need for further evaluation?

  • A. decrease in heart rate
  • B. increase in blood pressure
  • C. increase in pulse rate
  • D. no change in vital signs
Correct Answer: B

Rationale: The correct answer is B, an increase in blood pressure, which is most likely to indicate the need for further evaluation during the first stage of labor. An increase in blood pressure could signal potential complications like preeclampsia or hypertension, which require immediate attention to ensure the safety of both the laboring person and the baby.

A: A decrease in heart rate is not typically concerning during the first stage of labor, as it can be a normal response to relaxation or rest periods between contractions.
C: An increase in pulse rate is expected during labor as the body works harder, so it may not necessarily indicate a need for further evaluation unless it is excessively high.
D: No change in vital signs could be normal, but it is important to monitor for any signs of distress or complications even if vital signs remain stable.

The nurse is caring for a pregnant patient who is 24 weeks gestation and reports feeling dizzy when standing. What should the nurse recommend to the patient?

  • A. Take deep breaths and stand up quickly to relieve dizziness.
  • B. Sit down and drink a cold beverage to improve circulation.
  • C. Lie flat on your back immediately to prevent fainting.
  • D. Rise slowly from a seated or lying position and avoid standing for long periods.
Correct Answer: D

Rationale: The correct answer is D. When a pregnant patient feels dizzy, it can be due to postural hypotension. Rising slowly helps prevent a sudden drop in blood pressure. Standing for long periods can worsen symptoms. Option A is incorrect as standing up quickly can exacerbate dizziness. Option B is incorrect as cold beverages do not address the underlying issue. Option C is incorrect as lying flat on the back can decrease blood flow to the uterus.

What is the primary goal of using an epidural for pain management during labor?

  • A. to provide analgesia without sedation
  • B. to allow for movement and positioning
  • C. to relieve anxiety and promote relaxation
  • D. to allow for continuous monitoring
Correct Answer: A

Rationale: The primary goal of using an epidural during labor is to provide analgesia without sedation. Epidurals block pain signals, allowing the laboring individual to feel relief while remaining fully conscious. This helps manage labor pain effectively without causing sedation, allowing the individual to actively participate in the birthing process. Choice B is incorrect because epidurals can limit movement and positioning due to numbness. Choice C is incorrect as the main purpose is pain relief, not anxiety relief. Choice D is incorrect as continuous monitoring can be achieved through other methods, and it is not the primary goal of using an epidural.

A pregnant patient at 30 weeks gestation reports swelling in her legs and feet. Which of the following interventions should the nurse recommend?

  • A. Increase fluid intake to reduce swelling.
  • B. Lie down flat on your back to relieve swelling.
  • C. Elevate the legs while sitting or lying down.
  • D. Limit physical activity and avoid walking.
Correct Answer: C

Rationale: The correct answer is C: Elevate the legs while sitting or lying down. This intervention helps reduce swelling by promoting venous return and reducing fluid accumulation in the lower extremities. Elevating the legs helps gravity assist in returning blood back to the heart, reducing edema. Increasing fluid intake (A) may worsen swelling. Lying flat on the back (B) can restrict blood flow and worsen swelling. Limiting physical activity (D) can lead to decreased circulation and exacerbate swelling.

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