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The nurse auscultates the fetal heart rate and determines a rate of 152 bpm. Which nursing intervention is most appropriate at this time?
- A. Inform the mother that the fetal heart rate is normal.
- B. Reassess the fetal heart rate in 5 minutes because the rate is too high.
- C. Report the fetal heart rate to the physician or nurse-midwife immediately.
- D. Suggest to the mother that she is going to have a boy because the heart rate is fast.
Correct Answer: C
Rationale: The correct answer is C: Report the fetal heart rate to the physician or nurse-midwife immediately. A fetal heart rate of 152 bpm is within the normal range for a fetus, but it is essential to communicate any findings to the healthcare provider for further assessment and monitoring. This step ensures the safety and well-being of both the mother and the fetus by allowing the healthcare provider to determine if any additional actions are necessary.
Incorrect choices:
A: Inform the mother that the fetal heart rate is normal - While the heart rate may be normal, it is crucial to involve the healthcare provider for proper evaluation.
B: Reassess the fetal heart rate in 5 minutes because the rate is too high - 152 bpm is not considered too high, and immediate reporting to the healthcare provider is necessary.
D: Suggest to the mother that she is going to have a boy because the heart rate is fast - Fetal heart rate is not a reliable indicator of the baby's gender, and this
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What is the disadvantage of local anesthesia?
- A. decreased motor function
- B. nausea
- C. hypotension
- D. pain during injection
Correct Answer: D
Rationale: The correct answer is D: pain during injection. Local anesthesia may cause pain during injection due to the needle piercing the skin, which can be uncomfortable for the patient. This is a common disadvantage of local anesthesia.
A: Decreased motor function is not a typical disadvantage of local anesthesia as it mainly affects sensory nerves rather than motor nerves.
B: Nausea is not a direct side effect of local anesthesia as it does not affect the gastrointestinal system.
C: Hypotension is not a common disadvantage of local anesthesia, as it typically does not have a significant impact on blood pressure unless administered in large amounts or combined with other medications that can lower blood pressure.
A patient in active labor requests an epidural for pain management. What is the nurse's most appropriate intervention at this juncture?
- A. Assess the fetal heart rate pattern over the next 30 minutes.
- B. Take the patient's blood pressure every 5 minutes for 15 minutes.
- C. Determine the patient's contraction pattern for the next 30 minutes.
- D. Initiate an IV infusion of lactated Ringer's solution at 2000 mL/hour over 30 minutes.
Correct Answer: C
Rationale: The correct answer is C: Determine the patient's contraction pattern for the next 30 minutes. This is the most appropriate intervention as understanding the patient's contraction pattern is crucial in determining the stage of labor and the need for interventions like epidural. Assessing fetal heart rate (A) is important but not the immediate priority. Taking blood pressure (B) every 5 minutes is excessive and not directly related to the request for an epidural. Initiating an IV infusion of lactated Ringer's solution (D) is unnecessary and not indicated for pain management in labor. In summary, choice C is correct as it directly addresses the patient's current condition and guides further pain management decisions.
A patient presents to the labor and birth area for emergent birth. Vaginal exam reveals that the patient is fully dilated, vertex, +2 station, with ruptured membranes. The patient is extremely apprehensive because this is her first childbirth experience and asks for an epidural to be administered now. What is the priority nursing response based on this patient assessment?
- A. Use contact anesthesia for an epidural and prepare the patient per protocol.
- B. Tell the patient that she will not need any pain medication because the birth will be over in a matter of minutes and the pain will stop.
- C. Assist the patient with nonpharmacologic methods of pain distraction during this time as you prepare for vaginal birth.
- D. Call the physician for admitting orders.
Correct Answer: C
Rationale: The correct answer is C. In this scenario, the patient is fully dilated and at +2 station, indicating imminent birth. The priority nursing response should focus on assisting the patient with nonpharmacologic pain distraction methods as the birth is likely to occur soon. Nonpharmacologic pain management techniques such as breathing exercises, positioning changes, massage, and emotional support can help alleviate the patient's anxiety and provide comfort during this intense stage of labor. Administering an epidural at this late stage may not be feasible or effective due to the advanced stage of labor and imminent birth. Options A and D are not appropriate as they do not address the immediate needs of the patient in active labor. Option B is incorrect as it dismisses the patient's request for pain relief and fails to address her emotional and physical needs during labor.
Which comfort measure should the nurse utilize in order to enable a laboring woman to relax?
- A. Recommend frequent position changes.
- B. Palpate her filling bladder every 15 minutes.
- C. Offer warm wet cloths toN useR on Ithe GpatiBen.t'Cs faMce and neck. U S N T O
- D. Keep the room lights lit so the patient and her coach can see everything.
Correct Answer: C
Rationale: The correct answer is C because offering warm wet cloths to place on the patient's face and neck can help promote relaxation by providing a soothing sensation. This measure can help to reduce stress and tension, creating a calming environment for the laboring woman.
A: Recommending frequent position changes can help with labor progress and comfort, but it may not specifically address relaxation.
B: Palpating the filling bladder every 15 minutes is important for monitoring urinary output, but it is not a direct comfort measure for relaxation.
D: Keeping the room lights lit may be necessary for visibility, but bright lights can be distracting and may hinder relaxation.
Induction of labor is considered an acceptable obstetric procedure if it is a safe time to deliver the fetus. The charge nurse on the labor and birth unit is often asked to schedule patients for this procedure and therefore must be cognizant of the specific conditions appropriate for labor induction, including which of the following? (Select all that apply.)
- A. Fetal death
- B. Postterm pregnancy
- C. Rupture of membranes at or near term
- D. Convenience of the patient or her health care provider
Correct Answer: B
Rationale: The correct answer is B: Postterm pregnancy. Induction of labor is considered appropriate for postterm pregnancies to prevent potential complications for the mother and fetus. Postterm pregnancy is defined as a pregnancy that extends beyond 42 weeks gestation, increasing the risk of stillbirth and other adverse outcomes. Therefore, inducing labor in postterm pregnancies can help to ensure the well-being of both the mother and fetus.
Rationale for Incorrect Choices:
A: Fetal death - Induction of labor is not appropriate in cases of fetal death as there is no live fetus to deliver.
C: Rupture of membranes at or near term - Rupture of membranes alone does not always necessitate induction of labor unless there are other medical indications.
D: Convenience of the patient or her health care provider - Induction of labor should not be performed for convenience but rather for medical reasons to ensure the safety of the mother and fetus.