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The nurse is preparing to initiate intravenous (IV) access on a patient in the active phase of labor. Which size IV cannula is best for this patient?
- A. 18-gauge
- B. 20-gauge
- C. 22-gauge
- D. 24-gauge
Correct Answer: B
Rationale: The correct answer is B: 20-gauge. During active labor, a larger IV cannula is recommended to accommodate rapid fluid administration and potential blood loss. A 20-gauge cannula provides a good balance between flow rate and patient comfort. An 18-gauge cannula (choice A) may be too large and cause discomfort, while 22-gauge (choice C) and 24-gauge (choice D) may not allow for adequate fluid administration in a timely manner.
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Which patient will be most receptive to teaching about nonpharmacologic pain control methods?
- A. Gravida 1, para 0, in transition
- B. Gravida 2, para 1, admitted at 8 cm
- C. Gravida 1, para 0, dilated 2 cm, 80% effaced
- D. Gravida 3, para 2, complaining of intense perineal pressure
Correct Answer: C
Rationale: The correct answer is C because the patient is dilated at 2 cm and 80% effaced, indicating early labor. This stage allows for the patient to be receptive to learning about nonpharmacologic pain control methods. The other choices are incorrect because they are in active labor or experiencing intense pressure, making it less ideal for teaching nonpharmacologic methods.
During labor a vaginal examination should be performed only when necessary because of the risk of
- A. infection.
- B. fetal injury.
- C. discomfort.
- D. perineal traum
Correct Answer: A
Rationale: Step 1: Vaginal examination during labor can introduce bacteria, leading to infection.
Step 2: Infections can be harmful to both the mother and the baby.
Step 3: Minimizing unnecessary vaginal exams reduces the risk of infection.
Summary: Choice A is correct because infection poses serious risks. Choices B, C, and D are incorrect as they do not directly address the primary risk associated with vaginal examinations during labor.
A patient in early labor is feeling anxious about the labor process. Which intervention would be most effective in reducing her anxiety?
- A. Explain the stages of labor and what to expect.
- B. Encourage her to focus on her breathing.
- C. Administer a sedative as prescribed.
- D. Limit visitors to reduce external stressors.
Correct Answer: A
Rationale: The correct answer is A. Explanation of the stages of labor and what to expect can help the patient understand the process, reducing uncertainty and anxiety. This empowers the patient and promotes a sense of control. Encouraging breathing techniques (B) can help manage pain but may not address the underlying anxiety. Administering sedatives (C) should be a last resort due to potential side effects. Limiting visitors (D) can help reduce stress, but addressing the patient's anxiety requires more direct intervention.
The nurse is monitoring a laboring patient who is using patterned breathing techniques. The patient suddenly complains of lightheadedness and tingling in her hands. What should the nurse do?
- A. Assist the patient to lie down and elevate her legs.
- B. Instruct the patient to breathe into her cupped hands.
- C. Provide the patient with oxygen via nasal cannula.
- D. Encourage the patient to continue breathing patterns as taught.
Correct Answer: B
Rationale: The correct answer is B: Instruct the patient to breathe into her cupped hands. This is because lightheadedness and tingling in hands may indicate hyperventilation from rapid breathing. Breathing into cupped hands helps rebreathe carbon dioxide, restoring balance. Choice A is incorrect as elevating legs increases blood flow to brain, worsening symptoms. Choice C is unnecessary as oxygen is not the issue. Choice D may exacerbate hyperventilation.
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.