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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.
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The nurse provides counter pressure to relieve pain and open the pelvis to help with fetal descent. What type of counter pressure is the nurse providing?
- A. hip squeeze
- B. perineal pressure
- C. shoulder pressure
- D. knee press
Correct Answer: A
Rationale: The correct answer is A: hip squeeze. The nurse uses hip squeeze to provide counter pressure during labor. This technique helps relieve pain, open the pelvis, and facilitate fetal descent. By applying pressure on the hips, the nurse can help alleviate discomfort and create more space for the baby to move down the birth canal. Perineal pressure (B) focuses on the perineum, shoulder pressure (C) is not typically used in this context, and knee press (D) is not a common technique for labor pain management.
Which patient will most likely have increased anxiety and tension during labor?
- A. Gravida 2 who refused any medication
- B. Gravida 2 who delivered a stillborn baby last year
- C. Gravida 1 who did not attend prepared childbirth classes
- D. Gravida 3 who has two children younger than 3 years
Correct Answer: B
Rationale: The correct answer is B. A patient who delivered a stillborn baby last year is more likely to experience increased anxiety and tension during labor due to previous traumatic experience. This can trigger fear and worry about the current pregnancy outcome, leading to heightened emotional distress.
Incorrect Choices:
A: Refusing medication does not necessarily correlate with increased anxiety during labor.
C: Not attending childbirth classes may result in lack of knowledge but does not directly relate to increased anxiety during labor.
D: Having two children younger than 3 years may cause stress but does not specifically indicate increased anxiety during labor.
A patient in active labor asks about using a birth ball. What is the primary benefit of using a birth ball during labor?
- A. Provides a distraction from labor pain.
- B. Helps maintain proper fetal alignment.
- C. Increases the rate of cervical dilation.
- D. Reduces the likelihood of epidural anesthesia use.
Correct Answer: B
Rationale: The correct answer is B: Helps maintain proper fetal alignment. Using a birth ball during labor helps the mother maintain an upright position, which can aid in proper alignment of the fetus for an optimal birthing position. This can facilitate the progress of labor and potentially reduce the risk of complications.
A: Provides a distraction from labor pain - While using a birth ball may offer some distraction, the primary benefit is not pain management.
C: Increases the rate of cervical dilation - While movement and positioning can support the body's natural labor process, the birth ball itself does not directly increase cervical dilation rate.
D: Reduces the likelihood of epidural anesthesia use - While movement and positioning can sometimes help manage pain and reduce the need for epidural anesthesia, the primary benefit of the birth ball is more related to fetal alignment than pain management.
A laboring patient is 10 cm dilated; however, she does not feel the urge to push. The nurse understands that according to laboring down, the advantages of waiting until an urge to push are which of the following? (Select all that apply.)
- A. Less maternal fatigue
- B. Less birth canal injuries
- C. Decreased pushing time
- D. Faster descent of the fetus
Correct Answer: A
Rationale: The correct answer is A: Less maternal fatigue. Waiting for the urge to push during laboring down helps conserve the mother's energy and prevents exhaustion. Pushing without the urge can lead to ineffective pushing efforts, increasing maternal fatigue.
Incorrect choices:
B: Less birth canal injuries - Pushing without the urge may increase the risk of birth canal injuries due to ineffective pushing efforts.
C: Decreased pushing time - Pushing without the urge may actually prolong pushing time as the efforts may be less effective.
D: Faster descent of the fetus - Pushing without the urge may not necessarily result in faster descent of the fetus and can lead to prolonged labor.
For which patient should the oxytocin (Pitocin) infusion be discontinued immediately?
- A. A patient in transition with contractions every 2 minutes lasting 90 seconds each
- B. A patient in early labor with contractions every 5 minutes lasting 40 seconds each
- C. A patient in active labor with contractions every 3 minutes lasting 60 seconds each
- D. A patient in active labor with contractions every 2 to 3 minutes lasting 70 to 80 seconds each
Correct Answer: A
Rationale: The correct answer is A because a patient in transition with contractions every 2 minutes lasting 90 seconds each is experiencing very intense and frequent contractions, indicating high uterine activity. Discontinuing oxytocin infusion is crucial in this scenario to prevent hyperstimulation, which can lead to fetal distress or uterine rupture.
Choice B is incorrect because the patient is in early labor and the contractions are less frequent and less intense compared to the correct answer. Choice C is incorrect as the patient in active labor with contractions every 3 minutes lasting 60 seconds each is not as intense as the patient in transition in the correct answer. Choice D is incorrect because although the contractions are frequent and lasting longer, the intensity described in choice A is more concerning and requires immediate discontinuation of oxytocin infusion.