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A patient in early labor is feeling anxious about the labor process. Which intervention would be most effective in reducing her anxiety?
- A. Explain the stages of labor and what to expect.
- B. Encourage her to focus on her breathing.
- C. Administer a sedative as prescribed.
- D. Limit visitors to reduce external stressors.
Correct Answer: A
Rationale: The correct answer is A. Explanation of the stages of labor and what to expect can help the patient understand the process, reducing uncertainty and anxiety. This empowers the patient and promotes a sense of control. Encouraging breathing techniques (B) can help manage pain but may not address the underlying anxiety. Administering sedatives (C) should be a last resort due to potential side effects. Limiting visitors (D) can help reduce stress, but addressing the patient's anxiety requires more direct intervention.
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Which of the following factors would affect pain perception or tolerance for the laboring patient?
- A. Right occiput posterior fetal position during labor
- B. Bishop score of 10 prior to the induction of labor
- C. Gynecoid pelvis
- D. Absence of Ferguson's reflex
Correct Answer: A
Rationale: The correct answer is A: Right occiput posterior fetal position during labor. This position can lead to intense back pain and prolonged labor, affecting pain perception. A posterior position can put pressure on the sacrum and cause increased discomfort. In contrast, choices B, C, and D do not directly impact pain perception during labor. Choice B, Bishop score of 10, indicates favorable conditions for labor progress but does not necessarily affect pain perception. Choice C, Gynecoid pelvis, refers to a common pelvis shape that may facilitate labor but does not directly influence pain tolerance. Choice D, Absence of Ferguson's reflex, is related to the ability to push effectively but is not directly linked to pain perception.
What nursing intervention can be performed prior to epidural placement to potentially reduce a blood pressure drop?
- A. routine use of ephedrine
- B. IV fluid bolus
- C. insertion of indwelling urinary catheter
- D. upright positioning of the laboring person
Correct Answer: B
Rationale: The correct answer is B: IV fluid bolus. Prior to epidural placement, administering an IV fluid bolus can help prevent a drop in blood pressure by increasing preload and maintaining cardiac output. This helps offset the vasodilation effects of the epidural anesthesia. Options A, C, and D are incorrect. Ephedrine (A) is not routinely used before epidural placement due to its potential adverse effects. Insertion of a urinary catheter (C) is not directly related to preventing a blood pressure drop. Upright positioning (D) may actually worsen hypotension by pooling blood in the lower extremities.
During labor a vaginal examination should be performed only when necessary because of the risk of
- A. infection.
- B. fetal injury.
- C. discomfort.
- D. perineal traum
Correct Answer: A
Rationale: Step 1: Vaginal examination during labor can introduce bacteria, leading to infection.
Step 2: Infections can be harmful to both the mother and the baby.
Step 3: Minimizing unnecessary vaginal exams reduces the risk of infection.
Summary: Choice A is correct because infection poses serious risks. Choices B, C, and D are incorrect as they do not directly address the primary risk associated with vaginal examinations during labor.
The nurse is preparing to perform Leopold's maneuvers. Please select the rationale for the consistent use of these maneuvers by obstetric providers?
- A. To determine the status of the membranes
- B. To determine cervical dilation and effacement
- C. To determine the best location to assess the fetal heart rate
- D. To determine whether the fetus is in the posterior position
Correct Answer: C
Rationale: The correct answer is C because Leopold's maneuvers are used to determine the best location to assess the fetal heart rate. Step 1: Palpate the fundus to identify the fetal part. Step 2: Determine the fetal back to locate the fetal heart sounds. Step 3: Identify the presenting part. Step 4: Determine the position of the fetal head. This systematic approach helps assess fetal well-being. Choices A and B are incorrect because Leopold's maneuvers focus on fetal position and presentation, not membrane status or cervical dilation. Choice D is incorrect as it pertains to the fetal position, which is not the primary purpose of Leopold's maneuvers.
The best time to teach nonpharmacologic pain control methods to an unprepared laboring patient is during which stage?
- A. Latent phase
- B. Active phase
- C. Second stage
- D. Transition phase
Correct Answer: A
Rationale: The correct answer is A: Latent phase. This stage is ideal for teaching nonpharmacologic pain control methods as the patient is usually more receptive, relaxed, and able to focus. During the latent phase, contractions are typically mild and irregular, allowing the patient to learn and practice techniques effectively. In contrast, the active phase (choice B) is characterized by increased intensity and frequency of contractions, making it challenging for the patient to concentrate on learning. The second stage (choice C) is the pushing stage, where the focus shifts to pushing efforts rather than learning new techniques. The transition phase (choice D) is the most intense stage of labor, making it difficult for the patient to absorb and apply nonpharmacologic pain control methods effectively.