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A patient in active labor requests an epidural for pain management. What is the nurse's most appropriate intervention at this juncture?
- A. Assess the fetal heart rate pattern over the next 30 minutes.
- B. Take the patient's blood pressure every 5 minutes for 15 minutes.
- C. Determine the patient's contraction pattern for the next 30 minutes.
- D. Initiate an IV infusion of lactated Ringer's solution at 2000 mL/hour over 30 minutes.
Correct Answer: C
Rationale: The correct answer is C: Determine the patient's contraction pattern for the next 30 minutes. This is the most appropriate intervention as understanding the patient's contraction pattern is crucial in determining the stage of labor and the need for interventions like epidural. Assessing fetal heart rate (A) is important but not the immediate priority. Taking blood pressure (B) every 5 minutes is excessive and not directly related to the request for an epidural. Initiating an IV infusion of lactated Ringer's solution (D) is unnecessary and not indicated for pain management in labor. In summary, choice C is correct as it directly addresses the patient's current condition and guides further pain management decisions.
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The patient in labor experiences a spontaneous rupture of membranes. Which information related to this event must the nurse include in the patient's record?
- A. Fetal heart rate
- B. Pain level
- C. Test results ensuring that the fluid is not urine
- D. The patient's understanding of the event
Correct Answer: C
Rationale: The correct answer is C. Including test results ensuring that the fluid is not urine in the patient's record is crucial after a spontaneous rupture of membranes to confirm the presence of amniotic fluid, indicating the onset of labor. This information helps in assessing the progress of labor and ensuring the safety of both the mother and the fetus.
A: Fetal heart rate is important but not directly related to the spontaneous rupture of membranes. It should be monitored separately.
B: Pain level is subjective and can vary among individuals, not directly related to the rupture of membranes.
D: The patient's understanding of the event is important for communication but does not provide essential clinical information related to the rupture of membranes.
The nurse notes that a patient who has given birth 1 hour ago is touching her infant with her fingertips and talking to him softly in high-pitched tones. Based on this observation, which action should the nurse take?
- A. Request a social service consult for psychosocial support.
- B. Observe for other signs that the mother may not be accepting of the infant.
- C. Document this evidence of normal early maternal-infant attachment behavior.
- D. Determine whether the mother is too fatigued to interact normally with her infant.
Correct Answer: C
Rationale: The correct answer is C: Document this evidence of normal early maternal-infant attachment behavior. This is the correct action because the mother's behavior of touching her infant with her fingertips and talking to him softly in high-pitched tones is indicative of normal maternal-infant attachment. This behavior shows that the mother is engaging with her infant in a positive and nurturing way, which is crucial for bonding and attachment. It is important for the nurse to document this behavior as it reflects a healthy interaction between the mother and her newborn.
Other choices are incorrect:
A: Request a social service consult for psychosocial support - This choice is not necessary as the mother's behavior indicates normal attachment and does not suggest a need for psychosocial support at this time.
B: Observe for other signs that the mother may not be accepting of the infant - This choice is unnecessary as the mother's current behavior demonstrates acceptance and attachment towards her infant.
D: Determine whether the mother is too fatigued to interact normally
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
After insertion of the epidural catheter, what is the nurse's responsibility regarding patient care?
- A. monitoring vital signs every 5 to 15 minutes
- B. intermittent FHR monitoring
- C. providing the laboring person a meal
- D. instructing the laboring person to get out of bed to use the restroom
Correct Answer: A
Rationale: The correct answer is A: monitoring vital signs every 5 to 15 minutes. After inserting the epidural catheter, continuous monitoring of vital signs is crucial to detect any potential complications like hypotension or respiratory depression promptly. Vital signs include blood pressure, heart rate, respiratory rate, and oxygen saturation. Intermittent FHR monitoring (B) may be necessary but is not the primary responsibility after epidural insertion. Providing a meal (C) is contraindicated due to the risk of aspiration. Instructing the laboring person to get out of bed to use the restroom (D) is not recommended as they may be at risk of falls due to decreased sensation and muscle weakness from the epidural.
Which nursing assessment indicates that a patient who is in the second stage of labor is almost ready to give birth?
- A. Bloody mucous discharge increases.
- B. The vulva bulges and encircles the fetal hea
- C. The fetal head is felt at 0 station during the vaginal examination.
- D. The membranes rupture during a contraction.
Correct Answer: B
Rationale: The correct answer is B because the vulva bulging and encircling the fetal head is a sign that the baby is descending through the birth canal, indicating the patient is almost ready to give birth. This is known as crowning.
A: Bloody mucous discharge increasing is a sign of early labor, not necessarily indicating imminent birth.
C: Feeling the fetal head at 0 station means the baby is engaged in the pelvis, but it does not indicate the exact timing of birth.
D: Membranes rupturing during a contraction can happen at any stage of labor and do not necessarily signify imminent birth.