Nokea
During a vaginal exam, the nurse identifies that the fetal station is at +2. What does this finding indicate?
- A. The fetus is high in the pelvis.
- B. The presenting part is at the ischial spines.
- C. The presenting part is below the ischial spines.
- D. The presenting part is crowning.
Correct Answer: C
Rationale: The correct answer is C because when the fetal station is at +2, it indicates that the presenting part is below the ischial spines. This means the baby's head is 2 cm below the ischial spines, which is a significant milestone in the descent of the fetus through the birth canal. The other choices are incorrect because: A) +2 station indicates descent, not that the fetus is high in the pelvis; B) Ischial spines are at 0 station, not +2; D) Crowning is at +5 station, not +2.
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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.
What drug is an anxiolytic that relieves apprehension and creates a feeling of calm?
- A. hydroxyzine
- B. fentanyl
- C. codeine
- D. morphine
Correct Answer: A
Rationale: The correct answer is A: hydroxyzine. Hydroxyzine is an anxiolytic medication that acts on the central nervous system to relieve apprehension and induce a calming effect. It is commonly used to treat anxiety and tension. Fentanyl, codeine, and morphine are opioid medications primarily used for pain relief and do not have anxiolytic properties. Therefore, hydroxyzine is the correct choice for a drug that specifically targets anxiety and promotes a feeling of calm.
A major advantage of nonpharmacologic pain management is
- A. a more rapid labor is likely.
- B. more complete pain relief is possibl
- C. there are no side effects or risks to the fetus
- D. the woman remains fully alert at all times.
Correct Answer: C
Rationale: The correct answer is C because nonpharmacologic pain management methods, such as relaxation techniques or massage, do not involve medications that could potentially harm the fetus. This ensures there are no side effects or risks to the fetus during labor. Option A is incorrect as nonpharmacologic pain management does not necessarily guarantee a more rapid labor. Option B is incorrect because while nonpharmacologic methods can provide pain relief, it may not always be more complete compared to pharmacologic options. Option D is incorrect as some nonpharmacologic methods may alter alertness levels, such as hypnosis.
The nurse is providing care to a patient in the active phase of the first stage of labor. The patient is crying out loudly with each contraction. What is the nurse's most respectful approach for this patient?
- A. Ask the patient's labor coach if this is a usual expression of pain for her.
- B. Refer to the patient's chart to determine any orders for pain medication.
- C. Tell the patient that she is disturbing the other laboring patients on the unit.
- D. Encourage the patient to try to suppress her noisiness during contractions.
Correct Answer: A
Rationale: Step-by-step rationale for why Answer A is correct:
1. Asking the patient's labor coach shows respect for the patient's support person and acknowledges their insight into the patient's usual behavior.
2. It allows the nurse to gather information about the patient's pain expression without assuming or judging the situation.
3. This approach promotes patient-centered care and involves the patient's primary support system in decision-making.
4. It fosters open communication and partnership between the nurse, patient, and labor coach, enhancing the overall quality of care.
Summary:
- Option B is incorrect because pain medication should not be assumed without assessing the patient's current pain level first.
- Option C is incorrect as it lacks empathy and disregards the patient's emotional state during labor.
- Option D is incorrect as it suggests suppressing a natural response to pain, which may not be beneficial for the patient's coping mechanism.
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.