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The nurse is caring for a client in labor with her third baby. She is 39 weeks gestation, 6 cm dilated, 80% effaced, and 0 station, with minimal variability and recurrent variable decelerations. What action is the highest priority for the nurse?
- A. Administer oxygen
- B. Change maternal position
- C. Perform fetal scalp stimulation
- D. Perform vaginal examination
Correct Answer: B
Rationale: The correct answer is B: Change maternal position. This is the highest priority because the client is experiencing recurrent variable decelerations, which can indicate umbilical cord compression. Changing the maternal position can help relieve the pressure on the cord, potentially improving fetal oxygenation. Administering oxygen (choice A) can be important but addressing the cause of the variable decelerations is crucial. Performing fetal scalp stimulation (choice C) is not appropriate at this time as the focus should be on improving fetal oxygenation. Performing a vaginal examination (choice D) is not necessary at this moment and may even exacerbate the situation.
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A woman who states that she smokes 2 packs of cigarettes each day is admitted to the labor and delivery suite in labor. The nurse should monitor this labor for which of the following?
- A. Delayed placental separation.
- B. Late decelerations.
- C. Shoulder dystocia.
- D. Precipitous fetal descent.
Correct Answer: B
Rationale: Smoking during pregnancy is associated with placental insufficiency, which can lead to late decelerations in the fetal heart rate.
What is the purpose of initiating contractions in a contraction stress test (CST)?
- A. Increase placental blood flow.
- B. Identify fetal acceleration patterns.
- C. Determine the degree of fetal activity.
- D. Apply a stressful stimulus to the fetus.
Correct Answer: D
Rationale: The purpose of initiating contractions in a contraction stress test (CST) is to apply a stressful stimulus to the fetus to assess its response to stress, mimicking the stress of labor. This helps evaluate fetal well-being by monitoring the fetal heart rate during contractions. A: Increasing placental blood flow is not the primary purpose of CST. B: Identifying fetal acceleration patterns is not the main goal of CST. C: Determining the degree of fetal activity is not the primary objective of CST. The correct answer is D as it reflects the main purpose of initiating contractions in a CST.
The labor nurse is reviewing breathing techniques with a primiparous patient admitted for induction of labor. When is the best time to encourage the laboring patient to use slow, deep chest breathing with contractions?
- A. During labor, when she can no longer talk through contractions
- B. During the first stage of labor, when the contractions are 3 to 4 minutes apart
- C. Between contractions, during the transitional phase of the first stage of labor
- D. Between her efforts to push to facilitate relaxation between contractions
Correct Answer: A
Rationale: The correct answer is A: During labor, when she can no longer talk through contractions. This is the best time to encourage slow, deep chest breathing as it helps the laboring patient stay calm, focused, and manage pain effectively during the intense active phase of labor. When a woman reaches the point where she can no longer talk through contractions, it indicates that she is in the active phase of labor and may benefit from slow, deep breathing to help cope with the intensity of contractions.
Explanation for why other choices are incorrect:
B: During the first stage of labor, when the contractions are 3 to 4 minutes apart - Contractions being 3 to 4 minutes apart may not necessarily indicate the active phase of labor requiring slow, deep breathing.
C: Between contractions, during the transitional phase of the first stage of labor - Transitional phase contractions are typically intense and close together, making it less ideal for relaxation breathing between contractions.
D: Between her efforts
The health care practitioner caring for a pregnant client diagnosed with gonorrhea writes the following order: ceftriaxone 250 mg IM × one dose. The medication is available in 1-gram vials. The nurse adds 8 mL of normal saline to the vial. How many mL of the medication should the nurse administer? Calculate to the nearest whole.
- A. 2 mL
- B. 3 mL
- C. 4 mL
- D. 5 mL
Correct Answer: A
Rationale: The nurse should administer 2 mL of the medication. The calculation is based on the concentration of the medication after dilution.
A relaxation technique that can be used during the childbirth experience to decrease maternal pain perception is
- A. using increased environmental stimulation as a method of distraction.
- B. restricting family and friends from visiting during the labor period to keep the patient focused on breathing techniques.
- C. medicating the patient frequently to reduce pain perception.
- D. assisting the patient in breathing methods aimed at taking control of pain perception based on the contraction pattern.
Correct Answer: D
Rationale: Step-by-step rationale for why answer D is correct:
1. Breathing techniques help in managing pain perception during labor.
2. By assisting the patient in breathing methods, she gains control over her pain perception.
3. Controlled breathing can help distract from the intensity of contractions.
4. By focusing on breathing patterns, the patient can stay calm and manage pain effectively.
Summary:
A, B, and C are incorrect because they do not address pain management directly through breathing techniques. Option A relies on distraction, B focuses on isolation rather than coping mechanisms, and C suggests heavy reliance on medication rather than self-control.