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A pregnant woman in labor is quite anxious and has been breathing rapidly during contractions. She now complains of a tingling sensation in her fingers. What is the priority nursing intervention at this time?
- A. Perform a vaginal exam to denote progress.
- B. Reposition the patient to a side lying position.
- C. Instruct the patient to breathe into her cupped hands.
- D. Notify the physician about current findings.
Correct Answer: B
Rationale: The correct answer is B: Reposition the patient to a side lying position. This is the priority intervention because the tingling sensation in the fingers could be a sign of hyperventilation, which can lead to respiratory alkalosis. Repositioning the patient to a side lying position can help optimize oxygenation and reduce the risk of hyperventilation by promoting better breathing mechanics. Performing a vaginal exam (A) is not necessary at this time and could increase the patient's anxiety. Instructing the patient to breathe into her cupped hands (C) may not address the underlying issue of hyperventilation. Notifying the physician (D) is important but repositioning the patient should be done first to address the immediate physiological need.
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The nurse is preparing to administer a vaginal prostaglandin preparation to ripen the cervix of her patient. With which patient should the nurse question the use of vaginal prostaglandin as a cervical ripening agent?
- A. The patient who has a Bishop's score of 5
- B. The patient who is at 42 weeks of gestation
- C. The patient who had a previous low transverse cesarean birth
- D. The patient who had previous surgery in the upper uterus
Correct Answer: D
Rationale: The correct answer is D because a patient with previous surgery in the upper uterus is at risk for uterine rupture with prostaglandin use. Previous surgery in the upper uterus may weaken the uterine wall, increasing the risk of complications such as uterine rupture during cervical ripening.
A: Bishop's score of 5 indicates a moderate readiness for induction, making vaginal prostaglandin appropriate.
B: 42 weeks of gestation is considered post-term, where cervical ripening is often needed.
C: Previous low transverse cesarean birth is not a contraindication for prostaglandin use for cervical ripening.
After a forceps-assisted birth, the patient is observed to have continuous bright red lochia and a firm fundus. Which other data would indicate the presence of a potential vaginal wall hematoma?
- A. Lack of an episiotomy
- B. Mild, intermittent perineal pain
- C. Lack of pain in the perineal area
- D. Edema and discoloration of the labia and perineum
Correct Answer: D
Rationale: The correct answer is D. Edema and discoloration of the labia and perineum indicate the presence of a potential vaginal wall hematoma. This is because hematoma can cause swelling and bruising in the affected area. Bright red lochia and a firm fundus are more indicative of postpartum hemorrhage, not vaginal wall hematoma. Choices A and C are not directly related to the presence of a vaginal wall hematoma. Mild, intermittent perineal pain (Choice B) is non-specific and can be present in various postpartum conditions. Thus, option D is the most relevant indicator of a potential vaginal wall hematoma in this scenario.
What is the term for a slow, deep inhalation through the nose and exhalation through the mouth before a contraction for preparation and after a contraction for release of tension from the contraction?
- A. pursed-lip breathing
- B. panting
- C. chanting
- D. cleansing breath
Correct Answer: D
Rationale: The correct answer is D: cleansing breath. This technique involves slow, deep inhalation through the nose and exhalation through the mouth to release tension. Pursed-lip breathing (A) is used for managing shortness of breath. Panting (B) is rapid, shallow breathing. Chanting (C) involves rhythmic speaking or singing. Cleansing breath (D) fits the description best as it focuses on deep, intentional breathing for relaxation and release of tension before and after a contraction.
The nurse is preparing to perform Leopold's maneuvers. Please select the rationale for the consistent use of these maneuvers by obstetric providers?
- A. To determine the status of the membranes
- B. To determine cervical dilation and effacement
- C. To determine the best location to assess the fetal heart rate
- D. To determine whether the fetus is in the posterior position
Correct Answer: C
Rationale: The correct answer is C because Leopold's maneuvers are used to determine the best location to assess the fetal heart rate. Step 1: Palpate the fundus to identify the fetal part. Step 2: Determine the fetal back to locate the fetal heart sounds. Step 3: Identify the presenting part. Step 4: Determine the position of the fetal head. This systematic approach helps assess fetal well-being. Choices A and B are incorrect because Leopold's maneuvers focus on fetal position and presentation, not membrane status or cervical dilation. Choice D is incorrect as it pertains to the fetal position, which is not the primary purpose of Leopold's maneuvers.
The nurse is monitoring a laboring patient who is using patterned breathing techniques. The patient suddenly complains of lightheadedness and tingling in her hands. What should the nurse do?
- A. Assist the patient to lie down and elevate her legs.
- B. Instruct the patient to breathe into her cupped hands.
- C. Provide the patient with oxygen via nasal cannula.
- D. Encourage the patient to continue breathing patterns as taught.
Correct Answer: B
Rationale: The correct answer is B: Instruct the patient to breathe into her cupped hands. This is because lightheadedness and tingling in hands may indicate hyperventilation from rapid breathing. Breathing into cupped hands helps rebreathe carbon dioxide, restoring balance. Choice A is incorrect as elevating legs increases blood flow to brain, worsening symptoms. Choice C is unnecessary as oxygen is not the issue. Choice D may exacerbate hyperventilation.