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The labor nurse is developing a plan of care for a patient admitted in active labor with
- A. On admission, vital signs were as follows: maternal heart rate (HR) 92 bpm; fetal rate (FHR) baseline, 150 to 160 bpm; blood pressure, 124/76 mm Hg; temperature 37.2° C (99° F). What is the priority nursing action for this patient?
- B. Fetal acoustic stimulation
- C. Assess temperature everyN 2 hRourIs G
- D. Change absorption pads under her hips every 2 hours
Correct Answer: A
Rationale: The correct answer is A: On admission, vital signs were as follows: maternal heart rate (HR) 92 bpm; fetal rate (FHR) baseline, 150 to 160 bpm; blood pressure, 124/76 mm Hg; temperature 37.2° C (99° F). The priority nursing action for this patient is to assess the vital signs. The maternal heart rate, fetal heart rate, blood pressure, and temperature are crucial indicators of the patient's and the fetus's well-being during labor. Monitoring these vital signs helps the nurse detect any abnormalities or signs of distress promptly, allowing for timely intervention.
Choice B, fetal acoustic stimulation, is not the priority at this stage as there are no indications in the question stem that suggest the need for this intervention. Choice C, assessing temperature every 2 hours, is not the priority as the patient's temperature is within normal range on admission. Choice D, changing absorption pads under her hips every 2 hours,
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A patient in active labor is experiencing hypotension after receiving an epidural block. What is the nurse's first action?
- A. Administer a fluid bolus as prescribed.
- B. Elevate the patient's legs.
- C. Place the patient in a side-lying position.
- D. Notify the anesthesiologist immediately.
Correct Answer: C
Rationale: The correct answer is C. Placing the patient in a side-lying position is the first action because it helps to improve venous return, cardiac output, and blood pressure by increasing blood flow to the heart and brain. This can help alleviate hypotension associated with epidural block. Elevating the legs (choice B) may not be as effective in improving blood flow in this situation. Administering a fluid bolus (choice A) may be necessary but should not be the initial action. Notifying the anesthesiologist (choice D) is important, but addressing the patient's immediate physiological needs should come first.
The nurse is preparing a patient for a cesarean birth scheduled to be performed under general anesthesia. Which should the nurse plan to administer, if ordered by the health care provider, to prevent aspiration of gastric contents?
- A. Citric acid (Bicitra)
- B. Ranitidine (Zantac)
- C. Hydroxyzine (Vistaril)
- D. Glycopyrrolate (Robinul)
Correct Answer: C
Rationale: The correct answer is C: Hydroxyzine (Vistaril). Hydroxyzine is a first-generation antihistamine with antiemetic properties that can help reduce the risk of aspiration of gastric contents during general anesthesia. It works by decreasing nausea and vomiting, which in turn decreases the likelihood of aspiration. Citric acid (Bicitra) can actually increase gastric acidity and promote aspiration. Ranitidine (Zantac) is a histamine-2 receptor antagonist used to reduce gastric acid secretion but does not directly prevent aspiration. Glycopyrrolate (Robinul) is an anticholinergic medication used to reduce secretions but does not specifically target prevention of aspiration. Therefore, hydroxyzine is the most appropriate choice in this scenario.
Which method of pain management would be safest for a gravida 3, para 2, admitted at 8 cm cervical dilation?
- A. Narcotics
- B. Spinal block
- C. Epidural anesthesia
- D. Breathing and relaxation techniques
Correct Answer: C
Rationale: The correct answer is C: Epidural anesthesia. At 8 cm cervical dilation, the patient is in active labor and close to delivery. Epidural anesthesia is the safest method as it provides effective pain relief without affecting the baby's central nervous system. Narcotics can pass through the placenta and affect the baby's breathing. Spinal block may cause a sudden drop in blood pressure. Breathing and relaxation techniques may not be sufficient at 8 cm dilation. Epidural anesthesia is the most appropriate for pain management 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.
What nursing intervention can be performed prior to epidural placement to potentially reduce a blood pressure drop?
- 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: The correct answer is B: IV fluid bolus. Prior to epidural placement, administering an IV fluid bolus can help prevent a drop in blood pressure by increasing preload and maintaining cardiac output. This helps offset the vasodilation effects of the epidural anesthesia. Options A, C, and D are incorrect. Ephedrine (A) is not routinely used before epidural placement due to its potential adverse effects. Insertion of a urinary catheter (C) is not directly related to preventing a blood pressure drop. Upright positioning (D) may actually worsen hypotension by pooling blood in the lower extremities.