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The nurse is providing care to a patient in the active phase of the first stage of labor. The patient is crying out loudly with each contraction. What is the nurse's most respectful approach for this patient?
- A. Ask the patient's labor coach if this is a usual expression of pain for her.
- B. Refer to the patient's chart to determine any orders for pain medication.
- C. Tell the patient that she is disturbing the other laboring patients on the unit.
- D. Encourage the patient to try to suppress her noisiness during contractions.
Correct Answer: A
Rationale: Step-by-step rationale for why Answer A is correct:
1. Asking the patient's labor coach shows respect for the patient's support person and acknowledges their insight into the patient's usual behavior.
2. It allows the nurse to gather information about the patient's pain expression without assuming or judging the situation.
3. This approach promotes patient-centered care and involves the patient's primary support system in decision-making.
4. It fosters open communication and partnership between the nurse, patient, and labor coach, enhancing the overall quality of care.
Summary:
- Option B is incorrect because pain medication should not be assumed without assessing the patient's current pain level first.
- Option C is incorrect as it lacks empathy and disregards the patient's emotional state during labor.
- Option D is incorrect as it suggests suppressing a natural response to pain, which may not be beneficial for the patient's coping mechanism.
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A patient who is receiving oxytocin (Pitocin) infusion for the augmentation of labor is
- A. Which intervention would be a priority?
- B. Increase rate of Pitocin infusion to help spread out contraction pattern.
- C. Place oxygen on patient at 8 to 10 L/minute via face mask and turn patient to left
- D. Stop Pitocin infusion.
Correct Answer: A
Rationale: The correct answer is A because the priority intervention for a patient receiving oxytocin infusion for labor augmentation is to monitor fetal heart rate and uterine contractions. This is essential to ensure the safety of both the mother and the baby. Increasing the rate of Pitocin infusion (B) can lead to hyperstimulation and fetal distress. Providing oxygen and changing position (C) may be helpful in some situations but are not the priority. Stopping the Pitocin infusion (D) should only be done if there are signs of fetal distress or other complications.
A patient in active labor asks about using a birth ball. What is the primary benefit of using a birth ball during labor?
- A. Provides a distraction from labor pain.
- B. Helps maintain proper fetal alignment.
- C. Increases the rate of cervical dilation.
- D. Reduces the likelihood of epidural anesthesia use.
Correct Answer: B
Rationale: The correct answer is B: Helps maintain proper fetal alignment. Using a birth ball during labor helps the mother maintain an upright position, which can aid in proper alignment of the fetus for an optimal birthing position. This can facilitate the progress of labor and potentially reduce the risk of complications.
A: Provides a distraction from labor pain - While using a birth ball may offer some distraction, the primary benefit is not pain management.
C: Increases the rate of cervical dilation - While movement and positioning can support the body's natural labor process, the birth ball itself does not directly increase cervical dilation rate.
D: Reduces the likelihood of epidural anesthesia use - While movement and positioning can sometimes help manage pain and reduce the need for epidural anesthesia, the primary benefit of the birth ball is more related to fetal alignment than pain management.
A laboring patient is 10 cm dilated; however, she does not feel the urge to push. The nurse understands that according to laboring down, the advantages of waiting until an urge to push are which of the following? (Select all that apply.)
- A. Less maternal fatigue
- B. Less birth canal injuries
- C. Decreased pushing time
- D. Faster descent of the fetus
Correct Answer: A
Rationale: The correct answer is A: Less maternal fatigue. Waiting for the urge to push during laboring down helps conserve the mother's energy and prevents exhaustion. Pushing without the urge can lead to ineffective pushing efforts, increasing maternal fatigue.
Incorrect choices:
B: Less birth canal injuries - Pushing without the urge may increase the risk of birth canal injuries due to ineffective pushing efforts.
C: Decreased pushing time - Pushing without the urge may actually prolong pushing time as the efforts may be less effective.
D: Faster descent of the fetus - Pushing without the urge may not necessarily result in faster descent of the fetus and can lead to prolonged labor.
A laboring patient experiences a sudden rupture of membranes and the nurse observes a prolapsed cord. What is the nurse's priority action?
- A. Reposition the patient to relieve pressure on the cord.
- B. Immediately prepare the patient for a cesarean delivery.
- C. Administer oxygen at 10 L/min.
- D. Monitor the fetal heart rate continuously.
Correct Answer: A
Rationale: The correct answer is A: Reposition the patient to relieve pressure on the cord. This is the priority action because a prolapsed cord can lead to fetal compromise due to decreased blood flow. By repositioning the patient to a knee-chest or Trendelenburg position, gravity helps alleviate pressure on the cord. This action is crucial to prevent further compromise to the fetus.
Incorrect Choices:
B: Immediately prepare the patient for a cesarean delivery - While this may be necessary eventually, the immediate priority is to relieve pressure on the cord.
C: Administer oxygen at 10 L/min - Oxygen may be needed, but it is not the priority action in this emergency situation.
D: Monitor the fetal heart rate continuously - Monitoring is important, but repositioning the patient to relieve cord compression takes precedence.
What would the nurse administer if the newborn has decreased or no respiratory effort at delivery after the person received an opiate?
- A. naloxone (Narcan)
- B. acetaminophen (Tylenol)
- C. oxygen
- D. sodium bicarbonate
Correct Answer: A
Rationale: The correct answer is A: naloxone (Narcan). If a newborn has decreased or no respiratory effort after the mother received an opiate, it indicates potential opiate toxicity in the newborn. Naloxone is an opioid antagonist that can reverse the effects of opiates, including respiratory depression. Administering naloxone can help stimulate the newborn's respiratory effort, promoting adequate oxygenation.
Summary:
- A: Naloxone is the correct answer as it reverses opiate effects.
- B: Acetaminophen is a pain reliever and does not address respiratory depression.
- C: Oxygen may help with oxygenation but does not address the underlying opiate toxicity.
- D: Sodium bicarbonate is used to treat acid-base imbalances and does not address opiate toxicity or respiratory depression.