Nokea
A patient who is receiving oxytocin (Pitocin) infusion for the augmentation of labor is
- A. Which intervention would be a priority?
- B. Increase rate of Pitocin infusion to help spread out contraction pattern.
- C. Place oxygen on patient at 8 to 10 L/minute via face mask and turn patient to left
- D. Stop Pitocin infusion.
Correct Answer: A
Rationale: The correct answer is A because the priority intervention for a patient receiving oxytocin infusion for labor augmentation is to monitor fetal heart rate and uterine contractions. This is essential to ensure the safety of both the mother and the baby. Increasing the rate of Pitocin infusion (B) can lead to hyperstimulation and fetal distress. Providing oxygen and changing position (C) may be helpful in some situations but are not the priority. Stopping the Pitocin infusion (D) should only be done if there are signs of fetal distress or other complications.
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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.
Which aspect of newborn assessment may be limited by the application of a vacuum extractor at birth?
- A. Anterior fontanel
- B. Coronal suture lines
- C. Posterior fontanel
- D. Biparietal diameter
Correct Answer: C
Rationale: The correct answer is C: Posterior fontanel. When a vacuum extractor is used during birth, it can cause swelling or molding of the baby's head, which may affect the assessment of the posterior fontanel. This fontanel is an important landmark for determining head size and shape. Swelling or molding can make it difficult to accurately assess the fontanel's size and shape, potentially impacting the overall assessment of the newborn's head.
A: The anterior fontanel is not typically affected by the use of a vacuum extractor.
B: The coronal suture lines are not directly impacted by the vacuum extractor.
D: The biparietal diameter can still be measured accurately even with molding caused by the vacuum extractor.
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.
Induction of labor is considered an acceptable obstetric procedure if it is a safe time to deliver the fetus. The charge nurse on the labor and birth unit is often asked to schedule patients for this procedure and therefore must be cognizant of the specific conditions appropriate for labor induction, including which of the following? (Select all that apply.)
- A. Fetal death
- B. Postterm pregnancy
- C. Rupture of membranes at or near term
- D. Convenience of the patient or her health care provider
Correct Answer: B
Rationale: The correct answer is B: Postterm pregnancy. Induction of labor is considered appropriate for postterm pregnancies to prevent potential complications for the mother and fetus. Postterm pregnancy is defined as a pregnancy that extends beyond 42 weeks gestation, increasing the risk of stillbirth and other adverse outcomes. Therefore, inducing labor in postterm pregnancies can help to ensure the well-being of both the mother and fetus.
Rationale for Incorrect Choices:
A: Fetal death - Induction of labor is not appropriate in cases of fetal death as there is no live fetus to deliver.
C: Rupture of membranes at or near term - Rupture of membranes alone does not always necessitate induction of labor unless there are other medical indications.
D: Convenience of the patient or her health care provider - Induction of labor should not be performed for convenience but rather for medical reasons to ensure the safety of the mother and fetus.
A labor patient has brought in a photograph of her two children and asks the nurse to place it on the wall so that she can look at it during labor contractions. This is an example of
- A. focal point.
- B. distraction.
- C. effleurag
- D. relaxation
Correct Answer: A
Rationale: The correct answer is A: focal point. Placing the photograph on the wall serves as a focal point for the laboring patient, helping her to concentrate and stay focused during contractions. By having a specific point of visual focus, the patient can channel her energy and emotions towards the photo, providing a sense of comfort and motivation. It can also serve as a source of inspiration and reminder of the joy of motherhood, which can help in managing the pain and anxiety of labor.
Summary of other choices:
B: Distraction - While the photograph may provide a distraction, the primary purpose is to serve as a focal point for the patient.
C: Effleurage - Effleurage is a massage technique used in labor, not related to placing a photograph on the wall.
D: Relaxation - While the photograph may help in relaxation indirectly by providing comfort and focus, the primary purpose is not relaxation but rather concentration and emotional support.