Nokea
The nurse receives orders for pharmacologic pain relief. What does the nurse explain to the laboring person after administering fentanyl?
- A. "I will need to monitor your oxygen saturation."
- B. "It's important for me to insert a Foley catheter."
- C. "I will need to monitor for vaginal bleeding."
- D. "It's important for me to check your cervix after I administer this medication."
Correct Answer: A
Rationale: Rationale: After administering fentanyl, the nurse explains the need to monitor oxygen saturation due to the potential respiratory depression as a side effect of the medication. This is crucial for early detection and intervention. Monitoring for vaginal bleeding (C) is unrelated to fentanyl administration. Inserting a Foley catheter (B) and checking the cervix (D) are not necessary post-fentanyl administration. Oxygen saturation monitoring is the priority for patient safety.
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Which patient at term should proceed to the hospital or birth center the immediately after labor begins?
- A. Gravida 2, para 1, who lives 10 minutes away
- B. Gravida 1, para 0, who lives 40 minutes away
- C. Gravida 2, para 1, whose first labor lasted 16 hours
- D. Gravida 3, para 2, whose longest previous labor was 4 hours
Correct Answer: D
Rationale: The correct answer is D because the patient is gravida 3, para 2, with a history of the shortest previous labor of 4 hours. This indicates a high likelihood of rapid labor progression, necessitating immediate hospital or birth center access to ensure timely delivery. Choice A lives 10 minutes away, which may not be enough time in case of rapid labor. Choice B, living 40 minutes away, poses a risk of delivering en route. Choice C's previous labor duration of 16 hours suggests a longer labor, making immediate hospital arrival less critical.
Which aspect of newborn assessment may be limited by the application of a vacuum extractor at birth?
- A. Anterior fontanel
- B. Coronal suture lines
- C. Posterior fontanel
- D. Biparietal diameter
Correct Answer: C
Rationale: The correct answer is C: Posterior fontanel. When a vacuum extractor is used during birth, it can cause swelling or molding of the baby's head, which may affect the assessment of the posterior fontanel. This fontanel is an important landmark for determining head size and shape. Swelling or molding can make it difficult to accurately assess the fontanel's size and shape, potentially impacting the overall assessment of the newborn's head.
A: The anterior fontanel is not typically affected by the use of a vacuum extractor.
B: The coronal suture lines are not directly impacted by the vacuum extractor.
D: The biparietal diameter can still be measured accurately even with molding caused by the vacuum extractor.
Which of the following behaviors would be applicable to a nursing diagnosis of "risk for injury" in a patient who is in labor?
- A. Length of second-stage labor is 2 hours.
- B. Patient has received an epidural for pain control during the labor process.
- C. Patient is using breathing techniques during contractions to maximize pain relief.
- D. Patient is receiving parenteral fluids during the course of labor to maintain hydration.
Correct Answer: A
Rationale: The correct answer is A: Length of second-stage labor is 2 hours. This is applicable to the nursing diagnosis of "risk for injury" in a patient in labor because a prolonged second-stage labor can increase the risk of injury to both the mother and the baby. A prolonged second stage can lead to issues such as fetal distress, maternal exhaustion, and increased risk of instrumental delivery or cesarean section.
Explanation for why the other choices are incorrect:
B: Patient has received an epidural for pain control during the labor process - This choice does not directly address the risk for injury in labor.
C: Patient is using breathing techniques during contractions to maximize pain relief - While breathing techniques can help with pain relief, it does not specifically address the risk for injury.
D: Patient is receiving parenteral fluids during the course of labor to maintain hydration - While hydration is important during labor, it does not directly address the risk for injury.
A major advantage of nonpharmacologic pain management is
- A. a more rapid labor is likely.
- B. more complete pain relief is possibl
- C. there are no side effects or risks to the fetus
- D. the woman remains fully alert at all times.
Correct Answer: C
Rationale: The correct answer is C because nonpharmacologic pain management methods, such as relaxation techniques or massage, do not involve medications that could potentially harm the fetus. This ensures there are no side effects or risks to the fetus during labor. Option A is incorrect as nonpharmacologic pain management does not necessarily guarantee a more rapid labor. Option B is incorrect because while nonpharmacologic methods can provide pain relief, it may not always be more complete compared to pharmacologic options. Option D is incorrect as some nonpharmacologic methods may alter alertness levels, such as hypnosis.
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.