Nokea
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.
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The nurse is monitoring the person's vital signs after the epidural is placed and notices a blood pressure of 80/50 mm Hg. What nursing intervention can be performed prior to the epidural placement to potentially reduce this side effect?
- A. routine use of ephedrine
- B. IV fluid bolus
- C. insertion of indwelling urinary catheter
- D. upright positioning of the laboring person
Correct Answer: B
Rationale: Correct Answer: B - IV fluid bolus
Rationale:
1. IV fluid bolus can help increase blood volume and improve blood pressure.
2. Adequate hydration is crucial before epidural placement to prevent hypotension.
3. Other choices are not directly related to improving blood pressure in this scenario.
Summary:
- A: Routine use of ephedrine is not recommended as a routine prophylactic measure.
- C: Insertion of indwelling urinary catheter is important for monitoring urine output but not for improving blood pressure.
- D: Upright positioning may help prevent hypotension after epidural, but it's not a pre-epidural intervention to address low blood pressure.
A pregnant woman in labor is quite anxious and has been breathing rapidly during contractions. She now complains of a tingling sensation in her fingers. What is the priority nursing intervention at this time?
- A. Perform a vaginal exam to denote progress.
- B. Reposition the patient to a side lying position.
- C. Instruct the patient to breathe into her cupped hands.
- D. Notify the physician about current findings.
Correct Answer: B
Rationale: The correct answer is B: Reposition the patient to a side lying position. This is the priority intervention because the tingling sensation in the fingers could be a sign of hyperventilation, which can lead to respiratory alkalosis. Repositioning the patient to a side lying position can help optimize oxygenation and reduce the risk of hyperventilation by promoting better breathing mechanics. Performing a vaginal exam (A) is not necessary at this time and could increase the patient's anxiety. Instructing the patient to breathe into her cupped hands (C) may not address the underlying issue of hyperventilation. Notifying the physician (D) is important but repositioning the patient should be done first to address the immediate physiological need.
Which patient will be most receptive to teaching about nonpharmacologic pain control methods?
- A. Gravida 1, para 0, in transition
- B. Gravida 2, para 1, admitted at 8 cm
- C. Gravida 1, para 0, dilated 2 cm, 80% effaced
- D. Gravida 3, para 2, complaining of intense perineal pressure
Correct Answer: C
Rationale: The correct answer is C because the patient is dilated at 2 cm and 80% effaced, indicating early labor. This stage allows for the patient to be receptive to learning about nonpharmacologic pain control methods. The other choices are incorrect because they are in active labor or experiencing intense pressure, making it less ideal for teaching nonpharmacologic methods.
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.
A patient in early labor is feeling anxious about the labor process. Which intervention would be most effective in reducing her anxiety?
- A. Explain the stages of labor and what to expect.
- B. Encourage her to focus on her breathing.
- C. Administer a sedative as prescribed.
- D. Limit visitors to reduce external stressors.
Correct Answer: A
Rationale: The correct answer is A. Explanation of the stages of labor and what to expect can help the patient understand the process, reducing uncertainty and anxiety. This empowers the patient and promotes a sense of control. Encouraging breathing techniques (B) can help manage pain but may not address the underlying anxiety. Administering sedatives (C) should be a last resort due to potential side effects. Limiting visitors (D) can help reduce stress, but addressing the patient's anxiety requires more direct intervention.