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The laboring person is anxious and hurting. What can the nurse do to help the laboring person?
- A. Offer her an epidural.
- B. Encourage frequent position changes.
- C. Explain that she has to care for two other persons.
- D. Tell them to call someone to come sit with them.
Correct Answer: B
Rationale: The correct answer is B because encouraging frequent position changes can help alleviate discomfort during labor by reducing pressure on certain areas and promoting better circulation. This also helps with the progression of labor. Choice A (Offer her an epidural) may be a valid option, but it should not be the first line of intervention for all laboring individuals. Choice C (Explain that she has to care for two other persons) is irrelevant and may increase anxiety. Choice D (Tell them to call someone to come sit with them) does not address the physical discomfort and is not a direct intervention to support the laboring person.
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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.
The nurse is caring for a patient in transition. Which sign is most indicative that this phase of labor is occurring?
- A. Regular contractions every 3 minutes lasting 60 seconds.
- B. Increased bloody show and complaints of pressure.
- C. The urge to push with each contraction.
- D. Cervical dilation of 4 to 5 cm.
Correct Answer: B
Rationale: The correct answer is B because increased bloody show and complaints of pressure are indicative of the transition phase of labor. This phase occurs when the cervix dilates from 8 to 10 cm and contractions are strong and close together. This is a sign that the baby is moving down the birth canal. The other choices are incorrect because A describes the active phase of labor, C indicates the second stage of labor, and D reflects early labor. B is the most appropriate choice as it specifically aligns with the characteristics of the transition phase.
What technique, usually reserved for low-risk persons, has been shown to decrease pain, encourage movement, decrease anxiety, shorten labor, and improve labor satisfaction?
- A. controlled breathing
- B. aromatherapy
- C. massage
- D. hydrotherapy
Correct Answer: D
Rationale: The correct answer is D: hydrotherapy. Hydrotherapy involves the use of water for pain relief and relaxation during labor. It helps decrease pain by providing buoyancy and reducing the pressure on joints. The warm water encourages movement and relaxation, which can shorten labor duration and improve satisfaction. Controlled breathing (A) can be helpful but may not provide the same physical benefits as hydrotherapy. Aromatherapy (B) may help with relaxation but does not have the same direct physical effects on pain and movement. Massage (C) can be beneficial, but hydrotherapy offers a more comprehensive approach to pain management and labor support.
A nurse is assisting a laboring patient with breathing techniques to reduce labor pain. Which technique involves exhaling slowly while concentrating on relaxing each muscle group?
- A. Cleansing breaths
- B. Slow-paced breathing
- C. Modified-paced breathing
- D. Effleurage
Correct Answer: B
Rationale: The correct answer is B: Slow-paced breathing. This technique involves exhaling slowly while focusing on relaxing each muscle group, which helps reduce labor pain. Slow-paced breathing promotes relaxation and reduces stress, making it an effective pain management technique during labor. Cleansing breaths (A) focus on deep breathing to clear the mind, not necessarily on muscle relaxation. Modified-paced breathing (C) involves breathing in a controlled pattern but may not specifically target muscle relaxation. Effleurage (D) is a massage technique involving light stroking movements, not breathing techniques for pain management.
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.