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Immediately following the forceps-assisted birth of an infant, which action should the nurse implement?
- A. Assess the infant for signs of traum
- B. Measure the circumference of the infant's hea
- C. Apply a cold pack to the infant's scalp.
- D. Give the infant prophylactic antibiotics.
Correct Answer: A
Rationale: The correct action is to assess the infant for signs of trauma (Choice A) because forceps-assisted birth can increase the risk of injury to the infant. By assessing for signs of trauma promptly, the nurse can identify any potential issues and initiate necessary interventions.
Choice B is incorrect because measuring the circumference of the infant's head is not necessary immediately after forceps-assisted birth.
Choice C is incorrect as applying a cold pack to the infant's scalp is not indicated unless there is a specific medical reason for it.
Choice D is incorrect because giving prophylactic antibiotics to the infant is not a standard practice following forceps-assisted birth unless there is a specific indication for infection prevention.
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The nurse is preparing to perform Leopold's maneuvers. Please select the rationale for the consistent use of these maneuvers by obstetric providers?
- A. To determine the status of the membranes
- B. To determine cervical dilation and effacement
- C. To determine the best location to assess the fetal heart rate
- D. To determine whether the fetus is in the posterior position
Correct Answer: C
Rationale: The correct answer is C because Leopold's maneuvers are used to determine the best location to assess the fetal heart rate. Step 1: Palpate the fundus to identify the fetal part. Step 2: Determine the fetal back to locate the fetal heart sounds. Step 3: Identify the presenting part. Step 4: Determine the position of the fetal head. This systematic approach helps assess fetal well-being. Choices A and B are incorrect because Leopold's maneuvers focus on fetal position and presentation, not membrane status or cervical dilation. Choice D is incorrect as it pertains to the fetal position, which is not the primary purpose of Leopold's maneuvers.
The nurse is caring for a patient in the fourth stage of labor. Which assessment findings should the nurse identify as a potential complication? (Select all that apply.)
- A. Soft boggy uterus
- B. Maternal temperature of 37.2°C (99F)
- C. High uterine fundus displaced to the right
- D. Intense vaginal pain unrelieved by analgesics
Correct Answer: A
Rationale: The correct answer is A: Soft boggy uterus. In the fourth stage of labor, the uterus should be firm and well-contracted to prevent postpartum hemorrhage. A soft, boggy uterus indicates uterine atony, a potential complication that can lead to excessive bleeding.
B: Maternal temperature of 37.2°C (99F) is within normal range and not indicative of a complication.
C: High uterine fundus displaced to the right could indicate a full bladder or uterine displacement, but it is not a direct sign of a complication in the fourth stage of labor.
D: Intense vaginal pain unrelieved by analgesics may be due to various reasons but is not a typical complication in the fourth stage of labor.
Nausea and vomiting are common discomforts in labor. When treating with promethazine, what must the nurse do when administering this medication?
- A. Administer subcutaneously.
- B. Never administer with an opioid.
- C. Dilute before IV administration.
- D. Never administer in first stage labor.
Correct Answer: C
Rationale: The correct answer is C: Dilute before IV administration. Promethazine is a vesicant and can cause tissue damage if not properly diluted before IV administration. Diluting the medication helps reduce the risk of phlebitis and tissue irritation. Administering it subcutaneously (A) can cause pain and irritation at the injection site. Administering with an opioid (B) can increase the risk of respiratory depression. Administering promethazine in first stage labor (D) is generally safe, but diluting before IV administration is still necessary to prevent adverse effects.
The method of anesthesia in labor that is considered the safest for the fetus is
- A. epidural block.
- B. pudendal block.
- C. local infiltration.
- D. spinal (subarachnoi
Correct Answer: A
Rationale: The correct answer is A: epidural block. Epidural anesthesia in labor is considered the safest for the fetus because it does not directly affect the baby's central nervous system. It provides effective pain relief for the mother while minimizing the risk of medication passing to the fetus. It also allows for adjustment of the dose as needed during labor.
Summary of why other choices are incorrect:
B: Pudendal block is a regional anesthesia technique that primarily provides pain relief to the perineum and does not affect the fetus directly.
C: Local infiltration anesthesia is limited in its coverage and may not provide adequate pain relief during labor.
D: Spinal (subarachnoid) anesthesia may lead to a rapid and significant drop in blood pressure, affecting fetal oxygenation and require careful monitoring.
The best time to teach nonpharmacologic pain control methods to an unprepared laboring patient is during which stage?
- A. Latent phase
- B. Active phase
- C. Second stage
- D. Transition phase
Correct Answer: A
Rationale: The correct answer is A: Latent phase. This stage is ideal for teaching nonpharmacologic pain control methods as the patient is usually more receptive, relaxed, and able to focus. During the latent phase, contractions are typically mild and irregular, allowing the patient to learn and practice techniques effectively. In contrast, the active phase (choice B) is characterized by increased intensity and frequency of contractions, making it challenging for the patient to concentrate on learning. The second stage (choice C) is the pushing stage, where the focus shifts to pushing efforts rather than learning new techniques. The transition phase (choice D) is the most intense stage of labor, making it difficult for the patient to absorb and apply nonpharmacologic pain control methods effectively.