Nokea
A patient is admitted to the labor and birth room in active labor; contractions are 4 to 5 minutes apart and last for 30 seconds. The nurse needs to perform a detailed assessment. When is the best time to ask questions or perform procedures?
- A. After the contraction is over
- B. When it is all right with the coach
- C. During the increment of the next contraction
- D. After administration of analgesic-anesthetic
Correct Answer: C
Rationale: The correct answer is C: During the increment of the next contraction. This is the best time for assessment as the patient is likely to be more focused and cooperative during this phase. Asking questions or performing procedures during the contraction or immediately after may be distracting or uncomfortable for the patient. Waiting until the contraction is over (choice A) may delay necessary assessment. Waiting for the coach's approval (choice B) may not always align with the patient's needs. Waiting until after administration of analgesic-anesthetic (choice D) may not be timely for necessary assessment and may also impact the patient's ability to provide accurate information.
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The nurse provides counter pressure to relieve pain and open the pelvis to help with fetal descent. What type of counter pressure is the nurse providing?
- A. hip squeeze
- B. perineal pressure
- C. shoulder pressure
- D. knee press
Correct Answer: A
Rationale: The correct answer is A: hip squeeze. The nurse uses hip squeeze to provide counter pressure during labor. This technique helps relieve pain, open the pelvis, and facilitate fetal descent. By applying pressure on the hips, the nurse can help alleviate discomfort and create more space for the baby to move down the birth canal. Perineal pressure (B) focuses on the perineum, shoulder pressure (C) is not typically used in this context, and knee press (D) is not a common technique for labor pain management.
The nurse receives orders for pharmacologic pain relief. What does the nurse explain to the laboring person after administering fentanyl?
- A. "I will need to monitor your oxygen saturation."
- B. "It's important for me to insert a Foley catheter."
- C. "I will need to monitor for vaginal bleeding."
- D. "It's important for me to check your cervix after I administer this medication."
Correct Answer: A
Rationale: Rationale: After administering fentanyl, the nurse explains the need to monitor oxygen saturation due to the potential respiratory depression as a side effect of the medication. This is crucial for early detection and intervention. Monitoring for vaginal bleeding (C) is unrelated to fentanyl administration. Inserting a Foley catheter (B) and checking the cervix (D) are not necessary post-fentanyl administration. Oxygen saturation monitoring is the priority for patient safety.
While developing an intrapartum care plan for the patient in early labor, it is important that the nurse recognize that psychosocial factors may influence a woman's experience of pain. These include which of the following? (Select all that apply.)
- A. Culture
- B. Anxiety and fear
- C. Support systems
- D. Preparation for childbirth
Correct Answer: A
Rationale: Rationale: Culture can significantly impact a woman's perception and experience of pain during labor due to cultural beliefs, practices, and attitudes towards childbirth. Cultural norms and values can influence pain management preferences, coping mechanisms, and communication styles. Understanding the patient's cultural background is crucial for providing culturally competent care and addressing her psychosocial needs.
Summary of other choices:
B: Anxiety and fear - While anxiety and fear can influence a woman's pain experience, they are not specific to psychosocial factors related to culture.
C: Support systems - Support systems can affect a woman's labor experience, but they do not specifically relate to the influence of psychosocial factors such as culture.
D: Preparation for childbirth - Although preparation for childbirth can impact pain perception, it is not directly related to the influence of psychosocial factors like culture.
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.
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.