Nokea
A patient in labor is approaching the transition stage and already has an epidural in place. An additional dose of medication has been prescribed and administered to the patient. Which priority intervention should be performed in order to evaluate the clinical response to treatment?
- A. Obtain a pain scale response from the patient based on a 0 to 10 scale.
- B. Document maternal blood pressure and fetal heart rates following medication administration and observe for any variations.
- C. Document intake and output on the electronic health record (EHR).
- D. Increase the flow rate of prescribed parenteral fluid to maintain hydration.
Correct Answer: B
Rationale: The correct answer is B. Document maternal blood pressure and fetal heart rates following medication administration and observe for any variations. This is because assessing maternal blood pressure and fetal heart rates can provide crucial information about the patient's response to the medication and the overall well-being of both the mother and the baby during labor. Any variations in these vital signs could indicate potential complications that need immediate attention.
Choice A is not the priority as pain assessment, though important, may not provide immediate information on the effectiveness of the medication in this critical stage of labor. Choice C, documenting intake and output, is not as critical as monitoring vital signs in this scenario. Choice D is also not the priority as increasing fluid rate, though important for hydration, may not be the immediate concern in evaluating the clinical response to the medication.
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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 of the following behaviors would be applicable to a nursing diagnosis of "risk for injury" in a patient who is in labor?
- A. Length of second-stage labor is 2 hours.
- B. Patient has received an epidural for pain control during the labor process.
- C. Patient is using breathing techniques during contractions to maximize pain relief.
- D. Patient is receiving parenteral fluids during the course of labor to maintain hydration.
Correct Answer: A
Rationale: The correct answer is A: Length of second-stage labor is 2 hours. This is applicable to the nursing diagnosis of "risk for injury" in a patient in labor because a prolonged second-stage labor can increase the risk of injury to both the mother and the baby. A prolonged second stage can lead to issues such as fetal distress, maternal exhaustion, and increased risk of instrumental delivery or cesarean section.
Explanation for why the other choices are incorrect:
B: Patient has received an epidural for pain control during the labor process - This choice does not directly address the risk for injury in labor.
C: Patient is using breathing techniques during contractions to maximize pain relief - While breathing techniques can help with pain relief, it does not specifically address the risk for injury.
D: Patient is receiving parenteral fluids during the course of labor to maintain hydration - While hydration is important during labor, it does not directly address the risk for injury.
The nurse is monitoring a patient in the active stage of labor. Which conditions associated with fetal compromise should the nurse monitor? (Select all that apply.)
- A. Maternal hypotension
- B. Fetal heart rate of 140 to 150 bpm
- C. Meconium-stained amniotic fluid
- D. Maternal fever"”38°C (100.4°F) or higher
Correct Answer: A
Rationale: The correct answer is A: Maternal hypotension. Maternal hypotension can lead to decreased perfusion to the placenta, compromising fetal oxygenation. Other choices are incorrect. B: A fetal heart rate of 140 to 150 bpm is within the normal range during labor. C: Meconium-stained amniotic fluid may indicate fetal distress but is not a direct condition associated with fetal compromise. D: Maternal fever can indicate infection but does not directly indicate fetal compromise in the active stage of labor.
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.
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.