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A patient in labor is requesting pain relief. What is the most appropriate intervention for a patient in the latent phase of labor?
- A. Administer an epidural block
- B. Provide non-pharmacological pain relief methods
- C. Administer narcotic analgesics
- D. Encourage the patient to push with each contraction
Correct Answer: B
Rationale: The correct answer is B: Provide non-pharmacological pain relief methods. In the latent phase of labor, the cervix is dilated up to 6 cm and the contractions are typically mild to moderate. Non-pharmacological methods like massage, breathing techniques, warm showers, and position changes are most appropriate as they help the patient relax and cope with the pain without interfering with the progress of labor. Administering an epidural block (A) is not recommended in the latent phase as it can slow down labor. Administering narcotic analgesics (C) can affect the baby and may not provide adequate pain relief. Encouraging the patient to push (D) is not appropriate in the latent phase as it can lead to exhaustion and may not be effective until the cervix is fully dilated.
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A nurse is caring for a pregnant woman who is at 40 weeks gestation and is experiencing a prolonged labor. Which of the following interventions is most appropriate to promote labor progression?
- A. Administer a sedative to help the patient rest.
- B. Encourage the patient to walk or change positions.
- C. Administer oxytocin to strengthen contractions.
- D. Perform a cesarean section immediately.
Correct Answer: B
Rationale: The correct answer is B: Encourage the patient to walk or change positions. This intervention helps to promote gravity-assisted descent of the fetus, aiding in cervical dilation and labor progression. Walking and changing positions can also help alleviate pain and discomfort, facilitate optimal fetal positioning, and prevent maternal exhaustion. Administering a sedative (A) can potentially slow down labor progress. Administering oxytocin (C) may be indicated in certain situations, but it is not the most appropriate initial intervention for promoting labor progression in this case. Performing a cesarean section (D) is not warranted unless there are specific medical indications for it, as it is a major surgical procedure with potential risks.
The nurse explains that the birth weight of monozygotic twins is frequently below average. What is the most likely cause?
- A. Inadequate space in the uterus
- B. Inadequate blood supply
- C. Inadequate maternal health
- D. Inadequate placental nutrition
Correct Answer: D
Rationale: The single placenta may not be able to provide adequate nutrition to two fetuses.
The nurse is educating a pregnant patient who is at 36 weeks gestation about the signs of labor. Which statement by the patient indicates effective teaching?
- A. I should report regular contractions that occur every 5 minutes for 1 hour.
- B. I should avoid drinking fluids until my contractions stop.
- C. If I lose my mucous plug, I should go to the hospital immediately.
- D. I should stay home and rest as long as my contractions are not painful.
Correct Answer: A
Rationale: The correct answer is A because reporting regular contractions occurring every 5 minutes for 1 hour is a key sign of active labor. This pattern indicates the onset of true labor and the need to seek medical attention.
Explanation:
1. Regular contractions every 5 minutes indicate active labor is likely.
2. Sustained contractions for an hour suggest progression of labor.
3. Seeking medical advice is crucial for appropriate management.
Incorrect Choices:
B. Incorrect. Staying hydrated is important during labor to prevent dehydration.
C. Incorrect. Losing the mucous plug is a sign of early labor, not an emergency.
D. Incorrect. Painful contractions are not the sole indicator of active labor; regularity is key.
A gravid woman who recently emigrated from mainland China is being seen at her first prenatal visit. She was never vaccinated in her home country. An injection to prevent which of the following communicable diseases should be administered to the woman during her pregnancy?
- A. Influenza.
- B. Mumps.
- C. Rubella.
- D. Varicella.
Correct Answer: A
Rationale: Influenza vaccination is safe and recommended during pregnancy to protect both the mother and fetus. Vaccines for Mumps, Rubella, and Varicella are live attenuated vaccines and are contraindicated during pregnancy.
A postpartum person is breastfeeding her newborn. What is the most appropriate action if the person is experiencing nipple pain?
- A. apply lanolin cream
- B. administer pain relief
- C. monitor the baby's latch
- D. provide distraction techniques
Correct Answer: B
Rationale: The correct answer is B: administer pain relief. Nipple pain during breastfeeding can be caused by various factors such as improper latch, engorgement, or infection. Administering pain relief can help alleviate the discomfort temporarily while addressing the root cause. Applying lanolin cream (choice A) may help with moisturizing the nipples but won't address the underlying issue causing the pain. Monitoring the baby's latch (choice C) is important for long-term prevention but may not provide immediate relief. Providing distraction techniques (choice D) is not addressing the physical pain and may not be effective in resolving the issue. Administering pain relief is the most appropriate immediate action to help the postpartum person manage the discomfort while addressing the cause of the pain.