Nokea
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.
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Which patient will be most receptive to teaching about nonpharmacologic pain control methods?
- A. Gravida 1, para 0, in transition
- B. Gravida 2, para 1, admitted at 8 cm
- C. Gravida 1, para 0, dilated 2 cm, 80% effaced
- D. Gravida 3, para 2, complaining of intense perineal pressure
Correct Answer: C
Rationale: The correct answer is C because the patient is dilated at 2 cm and 80% effaced, indicating early labor. This stage allows for the patient to be receptive to learning about nonpharmacologic pain control methods. The other choices are incorrect because they are in active labor or experiencing intense pressure, making it less ideal for teaching nonpharmacologic methods.
The nurse is caring for a patient in the fourth stage of labor. Which assessment findings should the nurse identify as a potential complication? (Select all that apply.)
- A. Soft boggy uterus
- B. Maternal temperature of 37.2°C (99F)
- C. High uterine fundus displaced to the right
- D. Intense vaginal pain unrelieved by analgesics
Correct Answer: A
Rationale: The correct answer is A: Soft boggy uterus. In the fourth stage of labor, the uterus should be firm and well-contracted to prevent postpartum hemorrhage. A soft, boggy uterus indicates uterine atony, a potential complication that can lead to excessive bleeding.
B: Maternal temperature of 37.2°C (99F) is within normal range and not indicative of a complication.
C: High uterine fundus displaced to the right could indicate a full bladder or uterine displacement, but it is not a direct sign of a complication in the fourth stage of labor.
D: Intense vaginal pain unrelieved by analgesics may be due to various reasons but is not a typical complication in the fourth stage of labor.
A multipara's labor plan includes the use of jet hydrotherapy during the active phase of labor. What is the priority patient assessment prior to assisting the patient with this request?
- A. Maternal pulse
- B. Maternal temperature
- C. Maternal blood pressure
- D. Maternal blood glucose level
Correct Answer: B
Rationale: The correct answer is B: Maternal temperature. The priority assessment before using jet hydrotherapy is to check the maternal temperature to ensure it is within normal limits. Elevated temperature can indicate infection, which could be exacerbated by hydrotherapy. Maternal pulse (A), blood pressure (C), and blood glucose level (D) are important assessments but are not the priority before using hydrotherapy. Pulse and blood pressure can be monitored during hydrotherapy, and blood glucose levels are typically not affected by hydrotherapy.
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.
What nursing intervention can be performed prior to epidural placement to potentially reduce a blood pressure drop?
- A. routine use of ephedrine
- B. IV fluid bolus
- C. insertion of indwelling urinary catheter
- D. upright positioning of the laboring person
Correct Answer: B
Rationale: The correct answer is B: IV fluid bolus. Prior to epidural placement, administering an IV fluid bolus can help prevent a drop in blood pressure by increasing preload and maintaining cardiac output. This helps offset the vasodilation effects of the epidural anesthesia. Options A, C, and D are incorrect. Ephedrine (A) is not routinely used before epidural placement due to its potential adverse effects. Insertion of a urinary catheter (C) is not directly related to preventing a blood pressure drop. Upright positioning (D) may actually worsen hypotension by pooling blood in the lower extremities.