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A patient in labor reports a feeling of burning pain during the second stage of labor. This type of pain is associated with
- A. visceral pain.
- B. tissue ischemi
- C. cervical dilation.
- D. somatic pain.
Correct Answer: D
Rationale: The correct answer is D: somatic pain. Somatic pain is caused by the activation of pain receptors in the skin, muscles, or bones. In the second stage of labor, the baby's head passes through the birth canal, stretching the pelvic floor muscles and causing pressure and stretching of the perineum. This results in somatic pain due to the activation of pain receptors in these structures. Visceral pain (choice A) is deep, dull pain from internal organs, not applicable here. Tissue ischemia (choice B) refers to inadequate blood supply causing tissue damage, not pain. Cervical dilation (choice C) is not typically associated with burning pain.
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A major advantage of nonpharmacologic pain management is
- A. a more rapid labor is likely.
- B. more complete pain relief is possibl
- C. there are no side effects or risks to the fetus
- D. the woman remains fully alert at all times.
Correct Answer: C
Rationale: The correct answer is C because nonpharmacologic pain management methods, such as relaxation techniques or massage, do not involve medications that could potentially harm the fetus. This ensures there are no side effects or risks to the fetus during labor. Option A is incorrect as nonpharmacologic pain management does not necessarily guarantee a more rapid labor. Option B is incorrect because while nonpharmacologic methods can provide pain relief, it may not always be more complete compared to pharmacologic options. Option D is incorrect as some nonpharmacologic methods may alter alertness levels, such as hypnosis.
Which fetal position increases the likelihood of a longer and more painful labor?
- A. Left occiput posterior
- B. Left occiput anterior
- C. Right occiput anterior
- D. Right occiput transverse
Correct Answer: A
Rationale: The correct answer is A: Left occiput posterior. In this position, the baby's head is facing the mother's sacrum, making labor longer and more painful due to the baby's position causing more pressure on the mother's back and pelvis. Left occiput anterior (B) and Right occiput anterior (C) are favorable positions for a smoother labor. Right occiput transverse (D) can also lead to a longer and more complicated labor, but not as much as Left occiput posterior.
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.
Which of the following describes the purpose of Leopold's maneuvers?
- A. To assess cervical dilation and effacement.
- B. To determine fetal presentation and position.
- C. To measure the frequency of contractions.
- D. To estimate the weight of the fetus.
Correct Answer: B
Rationale: The purpose of Leopold's maneuvers is to determine the fetal presentation and position. Step 1 assesses the fundal height and shape, indicating the fetal part. Step 2 locates the back or limbs. Step 3 determines the presenting part in the pelvis. Step 4 confirms the presenting part and its mobility. This method helps in identifying the optimal fetal position for delivery. Assessing cervical dilation and effacement (Choice A) is typically done through vaginal examination. Measuring the frequency of contractions (Choice C) and estimating the weight of the fetus (Choice D) are not objectives of Leopold's maneuvers.
A laboring patient has asked the nurse to assist her in utilizing a cutaneous stimulation strategy for pain management. The nurse would
- A. assist her into the shower.
- B. apply a heat pack to lower back.
- C. help her to create a relaxing mental scen
- D. encourage cleansing breaths and slow-paced breathing.
Correct Answer: B
Rationale: The correct answer is B because applying a heat pack to the lower back can help alleviate labor pain through cutaneous stimulation. Heat therapy can increase blood flow, relax muscles, and reduce pain perception. Choice A is not specific to cutaneous stimulation and may not provide effective pain relief. Choice C focuses on mental imagery, not cutaneous stimulation. Choice D, while helpful for pain management, does not involve cutaneous stimulation.