Nokea
The patient in labor experiences a spontaneous rupture of membranes. Which information related to this event must the nurse include in the patient's record?
- A. Fetal heart rate
- B. Pain level
- C. Test results ensuring that the fluid is not urine
- D. The patient's understanding of the event
Correct Answer: C
Rationale: The correct answer is C. Including test results ensuring that the fluid is not urine in the patient's record is crucial after a spontaneous rupture of membranes to confirm the presence of amniotic fluid, indicating the onset of labor. This information helps in assessing the progress of labor and ensuring the safety of both the mother and the fetus.
A: Fetal heart rate is important but not directly related to the spontaneous rupture of membranes. It should be monitored separately.
B: Pain level is subjective and can vary among individuals, not directly related to the rupture of membranes.
D: The patient's understanding of the event is important for communication but does not provide essential clinical information related to the rupture of membranes.
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The laboring person wants to use open glottis breathing for pushing. How can the nurse support the person?
- A. Encourage the person to breathe however is most comfortable.
- B. Tell the person they should hold their breath for 10 counts.
- C. Explain that open glottis pushing is not effective.
- D. Discuss that the health-care provider would not allow them to use that breathing.
Correct Answer: A
Rationale: The correct answer is A because open glottis breathing is a common technique during the pushing stage of labor as it helps prevent breath-holding and excessive pressure buildup. By encouraging the person to breathe however is most comfortable, the nurse supports their autonomy and allows them to effectively engage in open glottis breathing.
Choice B is incorrect because holding the breath for counts can lead to increased intra-abdominal pressure and is not recommended during pushing. Choice C is incorrect as open glottis breathing is an effective technique for pushing. Choice D is incorrect as healthcare providers typically support the individual's chosen breathing techniques during labor.
The nurse provides counter pressure to relieve pain and open the pelvis to help with fetal descent. What type of counter pressure is the nurse providing?
- A. hip squeeze
- B. perineal pressure
- C. shoulder pressure
- D. knee press
Correct Answer: A
Rationale: The correct answer is A: hip squeeze. The nurse uses hip squeeze to provide counter pressure during labor. This technique helps relieve pain, open the pelvis, and facilitate fetal descent. By applying pressure on the hips, the nurse can help alleviate discomfort and create more space for the baby to move down the birth canal. Perineal pressure (B) focuses on the perineum, shoulder pressure (C) is not typically used in this context, and knee press (D) is not a common technique for labor pain management.
What drug is an anxiolytic that relieves apprehension and creates a feeling of calm?
- A. hydroxyzine
- B. fentanyl
- C. codeine
- D. morphine
Correct Answer: A
Rationale: The correct answer is A: hydroxyzine. Hydroxyzine is an anxiolytic medication that acts on the central nervous system to relieve apprehension and induce a calming effect. It is commonly used to treat anxiety and tension. Fentanyl, codeine, and morphine are opioid medications primarily used for pain relief and do not have anxiolytic properties. Therefore, hydroxyzine is the correct choice for a drug that specifically targets anxiety and promotes a feeling of calm.
If a woman's fundus is soft 30 minutes after birth, the nurse's first action should be to
- A. massage the fundus.
- B. take the blood pressure
- C. increase blood supply to the hands and feet.
- D. notify the physician or nurse-midwif
Correct Answer: A
Rationale: The correct answer is A: massage the fundus. After childbirth, a soft fundus indicates uterine atony, which can lead to postpartum hemorrhage. Massaging the fundus helps stimulate contractions and reduce bleeding, promoting uterine tone. This intervention is crucial in preventing complications. Taking blood pressure (B) is important but not the priority in this situation. Increasing blood supply to the hands and feet (C) is not relevant to addressing uterine atony. Notifying the physician or nurse-midwife (D) can be done after initiating immediate intervention to manage the soft fundus.
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.