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After insertion of the epidural catheter, what is the nurse's responsibility regarding patient care?
- A. monitoring vital signs every 5 to 15 minutes
- B. intermittent FHR monitoring
- C. providing the laboring person a meal
- D. instructing the laboring person to get out of bed to use the restroom
Correct Answer: A
Rationale: The correct answer is A: monitoring vital signs every 5 to 15 minutes. After inserting the epidural catheter, continuous monitoring of vital signs is crucial to detect any potential complications like hypotension or respiratory depression promptly. Vital signs include blood pressure, heart rate, respiratory rate, and oxygen saturation. Intermittent FHR monitoring (B) may be necessary but is not the primary responsibility after epidural insertion. Providing a meal (C) is contraindicated due to the risk of aspiration. Instructing the laboring person to get out of bed to use the restroom (D) is not recommended as they may be at risk of falls due to decreased sensation and muscle weakness from the epidural.
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A laboring patient who imagines her body opening to let the baby out is using a mental technique called
- A. imagery.
- B. effleurag
- C. dissociation.
- D. distraction.
Correct Answer: A
Rationale: The correct answer is A: imagery. Imagery involves creating mental pictures or sensations to help focus and relax the mind. In this scenario, the laboring patient visualizes her body opening to facilitate the birthing process, which can help reduce anxiety and pain perception. Effleurage (B) is a massage technique, dissociation (C) is a coping strategy to mentally detach from pain, and distraction (D) involves diverting attention away from pain stimuli. However, in this case, the patient's focus on visualizing the birthing process aligns with the use of imagery.
During labor, a patient using hydrotherapy reports feeling faint. What is the nurse's priority intervention?
- A. Remove the patient from the water.
- B. Increase the room temperature.
- C. Provide additional fluids orally.
- D. Notify the physician immediately.
Correct Answer: A
Rationale: The correct answer is A: Remove the patient from the water. This is the priority intervention because the patient's safety is at risk due to feeling faint. Removing the patient from the water helps prevent potential drowning or injury. Increasing room temperature (choice B) may worsen the patient's condition by increasing heat stress. Providing additional fluids orally (choice C) may not address the immediate risk of fainting. Notifying the physician immediately (choice D) is important, but ensuring the patient's safety by removing them from the water takes precedence.
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 process of labor places significant metabolic demands on the obstetric patient. Which physiologic findings would be expected?
- A. Decreased maternal blood pressure as a result of stimulation of alpha receptors
- B. Uterine vasoconstriction as a result of stimulation of beta receptors
- C. Increased maternal demand for oxygen
- D. Increased blood flow to placenta because of catecholamine release
Correct Answer: C
Rationale: Step-by-step rationale for why choice C is correct:
1. Labor is a physically demanding process that requires increased energy expenditure.
2. Increased uterine activity during labor leads to higher oxygen consumption by the mother.
3. Maternal demand for oxygen increases to meet the metabolic needs of both the mother and the fetus.
4. Adequate oxygen supply is crucial to support the increased workload during labor.
Summary:
A: Incorrect. Labor typically leads to increased blood pressure due to sympathetic activation, not decreased.
B: Incorrect. Uterine vasoconstriction is not expected during labor as it needs adequate blood supply for contractions.
D: Incorrect. Catecholamine release during labor can lead to vasoconstriction, not increased blood flow to the placenta.
A laboring patient experiences a sudden rupture of membranes and the nurse observes a prolapsed cord. What is the nurse's priority action?
- A. Reposition the patient to relieve pressure on the cord.
- B. Immediately prepare the patient for a cesarean delivery.
- C. Administer oxygen at 10 L/min.
- D. Monitor the fetal heart rate continuously.
Correct Answer: A
Rationale: The correct answer is A: Reposition the patient to relieve pressure on the cord. This is the priority action because a prolapsed cord can lead to fetal compromise due to decreased blood flow. By repositioning the patient to a knee-chest or Trendelenburg position, gravity helps alleviate pressure on the cord. This action is crucial to prevent further compromise to the fetus.
Incorrect Choices:
B: Immediately prepare the patient for a cesarean delivery - While this may be necessary eventually, the immediate priority is to relieve pressure on the cord.
C: Administer oxygen at 10 L/min - Oxygen may be needed, but it is not the priority action in this emergency situation.
D: Monitor the fetal heart rate continuously - Monitoring is important, but repositioning the patient to relieve cord compression takes precedence.