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The nurse is caring for a patient in the fourth stage of labor. Which assessment findings should the nurse identify as a potential complication? (Select all that apply.)
- A. Soft boggy uterus
- B. Maternal temperature of 37.2°C (99F)
- C. High uterine fundus displaced to the right
- D. Intense vaginal pain unrelieved by analgesics
Correct Answer: A
Rationale: The correct answer is A: Soft boggy uterus. In the fourth stage of labor, the uterus should be firm and well-contracted to prevent postpartum hemorrhage. A soft, boggy uterus indicates uterine atony, a potential complication that can lead to excessive bleeding.
B: Maternal temperature of 37.2°C (99F) is within normal range and not indicative of a complication.
C: High uterine fundus displaced to the right could indicate a full bladder or uterine displacement, but it is not a direct sign of a complication in the fourth stage of labor.
D: Intense vaginal pain unrelieved by analgesics may be due to various reasons but is not a typical complication in the fourth stage of labor.
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The method of anesthesia in labor that is considered the safest for the fetus is
- A. epidural block.
- B. pudendal block.
- C. local infiltration.
- D. spinal (subarachnoi
Correct Answer: A
Rationale: The correct answer is A: epidural block. Epidural anesthesia in labor is considered the safest for the fetus because it does not directly affect the baby's central nervous system. It provides effective pain relief for the mother while minimizing the risk of medication passing to the fetus. It also allows for adjustment of the dose as needed during labor.
Summary of why other choices are incorrect:
B: Pudendal block is a regional anesthesia technique that primarily provides pain relief to the perineum and does not affect the fetus directly.
C: Local infiltration anesthesia is limited in its coverage and may not provide adequate pain relief during labor.
D: Spinal (subarachnoid) anesthesia may lead to a rapid and significant drop in blood pressure, affecting fetal oxygenation and require careful monitoring.
The laboring person is using hypnosis for comfort measures. How can the nurse support the person?
- A. Talk them through the contractions.
- B. Keep the lights on so that everyone can see.
- C. Keep the room quiet and dimly lit.
- D. During the contraction, ask them to rate the pain.
Correct Answer: C
Rationale: The correct answer is C because keeping the room quiet and dimly lit promotes relaxation and helps the person stay focused during hypnosis. Bright lights and noise can be distracting and increase stress levels. Talking them through contractions (Choice A) may disrupt their concentration on hypnosis. Asking them to rate pain during contractions (Choice D) can also be disruptive and may increase anxiety.
The nurse is teaching a childbirth education class. Which information regarding excessive pain in labor should the nurse include in the session?
- A. It usually results in a more rapid labor.
- B. It has no effect on the outcome of labor.
- C. It is considered to be a normal occurrenc
- D. It may result in decreased placental perfusion.
Correct Answer: D
Rationale: The correct answer is D because excessive pain in labor can lead to increased maternal stress, which may result in decreased placental perfusion, compromising oxygen and nutrient delivery to the fetus. This can have serious implications for the baby's well-being. Choices A, B, and C are incorrect because excessive pain in labor does not necessarily lead to a more rapid labor, has an effect on the labor outcome by potentially impacting placental perfusion, and is not considered a normal occurrence that should be disregarded.
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,
Immediately following the forceps-assisted birth of an infant, which action should the nurse implement?
- A. Assess the infant for signs of traum
- B. Measure the circumference of the infant's hea
- C. Apply a cold pack to the infant's scalp.
- D. Give the infant prophylactic antibiotics.
Correct Answer: A
Rationale: The correct action is to assess the infant for signs of trauma (Choice A) because forceps-assisted birth can increase the risk of injury to the infant. By assessing for signs of trauma promptly, the nurse can identify any potential issues and initiate necessary interventions.
Choice B is incorrect because measuring the circumference of the infant's head is not necessary immediately after forceps-assisted birth.
Choice C is incorrect as applying a cold pack to the infant's scalp is not indicated unless there is a specific medical reason for it.
Choice D is incorrect because giving prophylactic antibiotics to the infant is not a standard practice following forceps-assisted birth unless there is a specific indication for infection prevention.