Nokea
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.
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The patient in labor experiences a spontaneous rupture of membranes. Which information related to this event must the nurse include in the patient's record?
- A. Fetal heart rate
- B. Pain level
- C. Test results ensuring that the fluid is not urine
- D. The patient's understanding of the event
Correct Answer: C
Rationale: The correct answer is C. Including test results ensuring that the fluid is not urine in the patient's record is crucial after a spontaneous rupture of membranes to confirm the presence of amniotic fluid, indicating the onset of labor. This information helps in assessing the progress of labor and ensuring the safety of both the mother and the fetus.
A: Fetal heart rate is important but not directly related to the spontaneous rupture of membranes. It should be monitored separately.
B: Pain level is subjective and can vary among individuals, not directly related to the rupture of membranes.
D: The patient's understanding of the event is important for communication but does not provide essential clinical information related to the rupture of membranes.
While developing an intrapartum care plan for the patient in early labor, it is important that the nurse recognize that psychosocial factors may influence a woman's experience of pain. These include which of the following? (Select all that apply.)
- A. Culture
- B. Anxiety and fear
- C. Support systems
- D. Preparation for childbirth
Correct Answer: A
Rationale: Rationale: Culture can significantly impact a woman's perception and experience of pain during labor due to cultural beliefs, practices, and attitudes towards childbirth. Cultural norms and values can influence pain management preferences, coping mechanisms, and communication styles. Understanding the patient's cultural background is crucial for providing culturally competent care and addressing her psychosocial needs.
Summary of other choices:
B: Anxiety and fear - While anxiety and fear can influence a woman's pain experience, they are not specific to psychosocial factors related to culture.
C: Support systems - Support systems can affect a woman's labor experience, but they do not specifically relate to the influence of psychosocial factors such as culture.
D: Preparation for childbirth - Although preparation for childbirth can impact pain perception, it is not directly related to the influence of psychosocial factors like culture.
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.
Which comfort measure should the nurse utilize in order to enable a laboring woman to relax?
- A. Recommend frequent position changes.
- B. Palpate her filling bladder every 15 minutes.
- C. Offer warm wet cloths toN useR on Ithe GpatiBen.t'Cs faMce and neck. U S N T O
- D. Keep the room lights lit so the patient and her coach can see everything.
Correct Answer: C
Rationale: The correct answer is C because offering warm wet cloths to place on the patient's face and neck can help promote relaxation by providing a soothing sensation. This measure can help to reduce stress and tension, creating a calming environment for the laboring woman.
A: Recommending frequent position changes can help with labor progress and comfort, but it may not specifically address relaxation.
B: Palpating the filling bladder every 15 minutes is important for monitoring urinary output, but it is not a direct comfort measure for relaxation.
D: Keeping the room lights lit may be necessary for visibility, but bright lights can be distracting and may hinder relaxation.
A patient in active labor requests an epidural for pain management. What is the nurse's most appropriate intervention at this juncture?
- A. Assess the fetal heart rate pattern over the next 30 minutes.
- B. Take the patient's blood pressure every 5 minutes for 15 minutes.
- C. Determine the patient's contraction pattern for the next 30 minutes.
- D. Initiate an IV infusion of lactated Ringer's solution at 2000 mL/hour over 30 minutes.
Correct Answer: C
Rationale: The correct answer is C: Determine the patient's contraction pattern for the next 30 minutes. This is the most appropriate intervention as understanding the patient's contraction pattern is crucial in determining the stage of labor and the need for interventions like epidural. Assessing fetal heart rate (A) is important but not the immediate priority. Taking blood pressure (B) every 5 minutes is excessive and not directly related to the request for an epidural. Initiating an IV infusion of lactated Ringer's solution (D) is unnecessary and not indicated for pain management in labor. In summary, choice C is correct as it directly addresses the patient's current condition and guides further pain management decisions.