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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.
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Excessive anxiety during labor heightens the patient's sensitivity to pain by increasing
- A. muscle tension.
- B. the pain threshold.
- C. blood flow to the uterus.
- D. rest time between contractions.
Correct Answer: A
Rationale: The correct answer is A: muscle tension. Excessive anxiety can lead to increased muscle tension, which can amplify the perception of pain during labor. Tense muscles can make contractions feel more intense and uncomfortable. Increased anxiety does not directly affect the pain threshold (B), blood flow to the uterus (C), or rest time between contractions (D) in a way that would heighten sensitivity to pain. Thus, choice A is the most appropriate explanation for how anxiety impacts pain perception during labor.
You are preparing a patient for epidural placement by a nurse anesthetist in the LDR. Which interventions should be included in the plan of care? (Select all that apply.)
- A. Administer a bolus of 500 to 1000 mL of D normal saline prior to catheter placement.
- B. Have ephedrine availableN aUt bR eSdsI idNeG duTrB in. g C caOthM eter placement.
- C. Monitor blood pressure of patient frequently during catheter insertion and for the first 15 minutes of epidural administration.
- D. Insert a Foley catheter prior to epidural catheter placement.
Correct Answer: A
Rationale: The correct answer is A because administering a bolus of 500 to 1000 mL of D5 normal saline prior to catheter placement helps prevent hypotension, a common side effect of epidural anesthesia. This bolus helps maintain adequate fluid volume, which is crucial for hemodynamic stability during the procedure.
Choice B is incorrect because having ephedrine available is not a necessary intervention for preparing a patient for epidural placement.
Choice C is incorrect because while monitoring blood pressure is important during epidural administration, it should be done continuously rather than just for the first 15 minutes.
Choice D is incorrect because inserting a Foley catheter is not a routine intervention for epidural catheter placement and is not directly related to the procedure's success or safety.
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 thoroughly dries the infant immediately after birth primarily to
- A. reduce heat loss from evaporation.
- B. stimulate crying and lung expansion.
- C. increase blood supply to the hands and feet.
- D. remove maternal blood from the skin surfac
Correct Answer: A
Rationale: The correct answer is A because drying the infant helps reduce heat loss through evaporation, preventing hypothermia. Wet skin can lead to rapid heat loss. This is critical for newborns who are at risk of temperature instability.
Choice B is incorrect because drying the infant is not primarily done to stimulate crying and lung expansion. Choice C is incorrect because drying does not increase blood supply to the hands and feet. Choice D is incorrect because maternal blood is typically cleared from the infant's skin through other means, not primarily by drying.
Which clinical finding would be an indication to the nurse that the fetus may be compromised?
- A. Active fetal movements
- B. Fetal heart rate in the 140s
- C. Contractions lasting 90 seconds
- D. Meconium-stained amniotic fluid
Correct Answer: D
Rationale: The correct answer is D. Meconium-stained amniotic fluid indicates fetal distress due to possible hypoxia. Meconium in the fluid can lead to meconium aspiration syndrome, a serious condition. The other choices are incorrect because active fetal movements (A) and a fetal heart rate in the 140s (B) are normal signs of fetal well-being. Contractions lasting 90 seconds (C) could indicate labor progress but do not necessarily indicate fetal compromise.