Nokea
During labor a vaginal examination should be performed only when necessary because of the risk of
- A. infection.
- B. fetal injury.
- C. discomfort.
- D. perineal traum
Correct Answer: A
Rationale: Step 1: Vaginal examination during labor can introduce bacteria, leading to infection.
Step 2: Infections can be harmful to both the mother and the baby.
Step 3: Minimizing unnecessary vaginal exams reduces the risk of infection.
Summary: Choice A is correct because infection poses serious risks. Choices B, C, and D are incorrect as they do not directly address the primary risk associated with vaginal examinations during labor.
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Which nursing action is most appropriate for a laboring patient experiencing severe back pain due to a posterior fetal position?
- A. Offer narcotic analgesics for pain relief.
- B. Encourage frequent position changes.
- C. Provide continuous fetal monitoring.
- D. Prepare the patient for an immediate cesarean delivery.
Correct Answer: B
Rationale: The correct answer is B: Encourage frequent position changes. This is because changing positions can help alleviate pressure on the back and potentially help the baby rotate into a more favorable position for delivery. It is a non-invasive and supportive approach to managing back pain during labor. Offering narcotic analgesics (choice A) may provide temporary relief but does not address the underlying issue. Continuous fetal monitoring (choice C) is important but not the most immediate intervention for back pain. Immediately preparing for a cesarean delivery (choice D) is not warranted unless there are other concerning factors beyond back pain.
The nurse thoroughly dries the infant immediately after birth primarily to
- A. reduce heat loss from evaporation.
- B. stimulate crying and lung expansion.
- C. increase blood supply to the hands and feet.
- D. remove maternal blood from the skin surfac
Correct Answer: A
Rationale: The correct answer is A because drying the infant helps reduce heat loss through evaporation, preventing hypothermia. Wet skin can lead to rapid heat loss. This is critical for newborns who are at risk of temperature instability.
Choice B is incorrect because drying the infant is not primarily done to stimulate crying and lung expansion. Choice C is incorrect because drying does not increase blood supply to the hands and feet. Choice D is incorrect because maternal blood is typically cleared from the infant's skin through other means, not primarily by drying.
A nurse is assisting a laboring patient with breathing techniques to reduce labor pain. Which technique involves exhaling slowly while concentrating on relaxing each muscle group?
- A. Cleansing breaths
- B. Slow-paced breathing
- C. Modified-paced breathing
- D. Effleurage
Correct Answer: B
Rationale: The correct answer is B: Slow-paced breathing. This technique involves exhaling slowly while focusing on relaxing each muscle group, which helps reduce labor pain. Slow-paced breathing promotes relaxation and reduces stress, making it an effective pain management technique during labor. Cleansing breaths (A) focus on deep breathing to clear the mind, not necessarily on muscle relaxation. Modified-paced breathing (C) involves breathing in a controlled pattern but may not specifically target muscle relaxation. Effleurage (D) is a massage technique involving light stroking movements, not breathing techniques for pain management.
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 does the nurse explain to the laboring person and partner about nitrous oxide?
- A. It makes the newborn have respiratory depression.
- B. It causes the laboring person to have decreased respirations.
- C. It does not affect respiration as an opiate would.
- D. The mask is held to the person's face by the partner.
Correct Answer: C
Rationale: The correct answer is C because nitrous oxide does not affect respiration like an opiate would. Nitrous oxide is a safe option for pain relief during labor because it does not depress the respiratory system. It is self-administered by the laboring person and does not require assistance from the partner. Choices A and B are incorrect because nitrous oxide does not cause respiratory depression in the newborn or the laboring person. Choice D is incorrect because the laboring person holds the mask to their face themselves.