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The nurse is preparing to perform Leopold's maneuvers. Please select the rationale for the consistent use of these maneuvers by obstetric providers?
- A. To determine the status of the membranes
- B. To determine cervical dilation and effacement
- C. To determine the best location to assess the fetal heart rate
- D. To determine whether the fetus is in the posterior position
Correct Answer: C
Rationale: The correct answer is C because Leopold's maneuvers are used to determine the best location to assess the fetal heart rate. Step 1: Palpate the fundus to identify the fetal part. Step 2: Determine the fetal back to locate the fetal heart sounds. Step 3: Identify the presenting part. Step 4: Determine the position of the fetal head. This systematic approach helps assess fetal well-being. Choices A and B are incorrect because Leopold's maneuvers focus on fetal position and presentation, not membrane status or cervical dilation. Choice D is incorrect as it pertains to the fetal position, which is not the primary purpose of Leopold's maneuvers.
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What technique, usually reserved for low-risk persons, has been shown to decrease pain, encourage movement, decrease anxiety, shorten labor, and improve labor satisfaction?
- A. controlled breathing
- B. aromatherapy
- C. massage
- D. hydrotherapy
Correct Answer: D
Rationale: The correct answer is D: hydrotherapy. Hydrotherapy involves the use of water for pain relief and relaxation during labor. It helps decrease pain by providing buoyancy and reducing the pressure on joints. The warm water encourages movement and relaxation, which can shorten labor duration and improve satisfaction. Controlled breathing (A) can be helpful but may not provide the same physical benefits as hydrotherapy. Aromatherapy (B) may help with relaxation but does not have the same direct physical effects on pain and movement. Massage (C) can be beneficial, but hydrotherapy offers a more comprehensive approach to pain management and labor support.
A multipara's labor plan includes the use of jet hydrotherapy during the active phase of labor. What is the priority patient assessment prior to assisting the patient with this request?
- A. Maternal pulse
- B. Maternal temperature
- C. Maternal blood pressure
- D. Maternal blood glucose level
Correct Answer: B
Rationale: The correct answer is B: Maternal temperature. The priority assessment before using jet hydrotherapy is to check the maternal temperature to ensure it is within normal limits. Elevated temperature can indicate infection, which could be exacerbated by hydrotherapy. Maternal pulse (A), blood pressure (C), and blood glucose level (D) are important assessments but are not the priority before using hydrotherapy. Pulse and blood pressure can be monitored during hydrotherapy, and blood glucose levels are typically not affected by hydrotherapy.
The nurse detects hypotension in a laboring patient after an epidural. Which actions should the nurse plan to implement? (SeNleUctRaSllIthNatGaTpBpl.y.)C OM
- A. Encourage the patient to drink fluids.
- B. Place the patient in a Trendelenburg position.
- C. Administer a normal saline bolus as prescribe
- D. Administer oxygen at 8 to 10 L/minute per face mask.
Correct Answer: C
Rationale: The correct answer is C: Administer a normal saline bolus as prescribed. In this scenario, hypotension post-epidural could be due to vasodilation leading to decreased blood pressure. Administering a normal saline bolus can help increase intravascular volume and improve blood pressure. Encouraging the patient to drink fluids (A) may not provide immediate volume resuscitation. Placing the patient in a Trendelenburg position (B) can worsen hypotension by increasing pressure on the vena cava. Administering oxygen (D) may be helpful but addressing the hypotension with a saline bolus is the priority.
The nurse is monitoring the person's vital signs after the epidural is placed and notices a blood pressure of 80/50 mm Hg. What nursing intervention can be performed prior to the epidural placement to potentially reduce this side effect?
- A. routine use of ephedrine
- B. IV fluid bolus
- C. insertion of indwelling urinary catheter
- D. upright positioning of the laboring person
Correct Answer: B
Rationale: Correct Answer: B - IV fluid bolus
Rationale:
1. IV fluid bolus can help increase blood volume and improve blood pressure.
2. Adequate hydration is crucial before epidural placement to prevent hypotension.
3. Other choices are not directly related to improving blood pressure in this scenario.
Summary:
- A: Routine use of ephedrine is not recommended as a routine prophylactic measure.
- C: Insertion of indwelling urinary catheter is important for monitoring urine output but not for improving blood pressure.
- D: Upright positioning may help prevent hypotension after epidural, but it's not a pre-epidural intervention to address low blood pressure.
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.