Nokea
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.
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A woman who is gravida 3, para 2 enters the intrapartum unit. The most important nursing assessments include
- A. contraction pattern, amount of discomfort, and pregnancy history.
- B. fetal heart rate, maternal vital signs, and the woman's nearness to birth.
- C. last food intake, when labor began, and cultural practices the couple desires.
- D. identification of ruptured membranes, the woman's gravida and para, and access to a support person.
Correct Answer: B
Rationale: The correct answer is B because fetal heart rate, maternal vital signs, and the woman's nearness to birth are crucial assessments in the intrapartum period. Fetal heart rate indicates fetal well-being, maternal vital signs reflect maternal status, and assessing the nearness to birth helps in determining the stage of labor and necessary interventions.
A is incorrect because while contraction pattern and discomfort are important, pregnancy history is not as immediate a concern in the intrapartum period.
C is incorrect as last food intake and cultural practices are not the most critical assessments during labor.
D is incorrect because while identification of ruptured membranes is important, the woman's gravida and para are less immediate concerns compared to fetal heart rate and maternal vital signs.
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.
A maternal indication for the use of vacuum extraction is
- A. a wide pelvic outlet.
- B. maternal exhaustion.
- C. a history of rapid deliveries.
- D. failure to progress past 0 station.
Correct Answer: B
Rationale: The correct answer is B: maternal exhaustion. Vacuum extraction may be indicated when the mother is too exhausted to continue pushing, as it can assist in the delivery process. A wide pelvic outlet (choice A) may facilitate delivery but is not a specific indication for vacuum extraction. A history of rapid deliveries (choice C) does not necessarily require vacuum extraction. Failure to progress past 0 station (choice D) may indicate other interventions like cesarean section rather than vacuum extraction. Therefore, the most appropriate indication for vacuum extraction in this scenario is maternal exhaustion.
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.
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.