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What is the most appropriate nursing action when a laboring person requests pain relief during the first stage of labor?
- A. provide non-pharmacological pain relief
- B. administer epidural analgesia
- C. administer IV analgesics
- D. administer pain medication as requested
Correct Answer: B
Rationale: The correct answer is B: administer epidural analgesia. In the first stage of labor, epidural analgesia is the most appropriate option for pain relief as it provides effective and continuous pain management without compromising maternal and fetal well-being. Epidural analgesia allows the laboring person to remain alert and actively participate in the birthing process. Non-pharmacological pain relief methods may not provide sufficient pain relief during the intense contractions of the first stage of labor. Administering IV analgesics may not effectively manage the pain in the first stage and can have sedative effects on the laboring person and newborn. Administering pain medication as requested without considering the most appropriate option may not provide optimal pain relief and may not be in the best interest of the laboring person and their baby.
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A 34-week pregnant woman presents with a non-reactive nonstress test (NST). What should the nurse do next?
- A. Administer a tocolytic agent
- B. Perform a biophysical profile (BPP)
- C. Monitor the fetal heart rate for 30 minutes
- D. Monitor fetal heart rate
Correct Answer: B
Rationale: The correct answer is B: Perform a biophysical profile (BPP). A non-reactive NST indicates fetal distress, so a BPP is necessary to assess the overall well-being of the fetus. BPP evaluates fetal breathing movements, fetal movements, fetal tone, amniotic fluid volume, and NST results. Administering a tocolytic agent (A) is not indicated as the issue is fetal distress, not preterm labor. Monitoring the fetal heart rate for 30 minutes (C) may delay necessary intervention if fetal distress is present. Monitoring fetal heart rate (D) alone does not provide a comprehensive assessment of fetal well-being.
A pregnant woman must have a glucose challenge test (GCT). Which of the following should be included in the preprocedure teaching?
- A. Fast for 12 hours before the test.
- B. Bring a urine specimen to the laboratory on the day of the test.
- C. Be prepared to have 4 blood specimens taken on the day of the test.
- D. The test should take one hour to complete.
Correct Answer: D
Rationale: The glucose challenge test typically takes one hour to complete and does not require fasting or multiple blood specimens. A urine specimen is not required for this test.
A nurse is caring for a pregnant patient who is 28 weeks gestation and has been diagnosed with gestational diabetes. What is the nurse's priority teaching for this patient?
- A. Encourage the patient to exercise vigorously to manage blood sugar levels.
- B. Monitor blood glucose levels regularly and follow a balanced diet.
- C. Instruct the patient to limit fluid intake to prevent complications.
- D. Recommend insulin therapy immediately to control blood sugar levels.
Correct Answer: B
Rationale: The correct answer is B: Monitor blood glucose levels regularly and follow a balanced diet. This is the priority teaching for a pregnant patient with gestational diabetes because it focuses on managing blood sugar levels effectively. Regular monitoring helps the patient understand how their body responds to different foods and activities. Following a balanced diet helps maintain stable blood sugar levels and provides essential nutrients for the baby's development.
A: Encouraging vigorous exercise may not be safe during pregnancy, especially for a patient with gestational diabetes.
C: Limiting fluid intake is not a priority teaching for gestational diabetes and may lead to dehydration, which can be harmful during pregnancy.
D: Recommending insulin therapy immediately is not the first-line treatment for gestational diabetes. Lifestyle modifications like diet and exercise are usually tried first.
What is the primary goal of fetal heart rate monitoring during the second stage of labor?
- A. to predict when to bear down during contractions
- B. to determine the strength of the uterine contractions
- C. to evaluate fetal well-being
- D. to monitor vital signs of the birthing person
Correct Answer: C
Rationale: The primary goal of fetal heart rate monitoring during the second stage of labor is to evaluate fetal well-being. This is crucial to ensure that the baby is tolerating labor and delivery well. Monitoring fetal heart rate helps identify any signs of distress or compromise in oxygen supply to the baby. It guides healthcare providers in making timely interventions if needed to prevent adverse outcomes. Choices A and B are incorrect because the primary goal is not about timing contractions or assessing uterine contractions strength. Choice D is incorrect as the focus is not on monitoring the vital signs of the birthing person but on assessing the well-being of the fetus.
A nurse is caring for a laboring person in the second stage of labor. What is the most appropriate intervention when the perineum starts to bulge?
- A. apply warm compresses to the perineum
- B. apply gentle pressure to the perineum
- C. prepare the person for episiotomy
- D. perform perineal massage
Correct Answer: B
Rationale: The correct answer is B: apply gentle pressure to the perineum. This intervention helps to support the perineum and reduce the risk of perineal tearing during childbirth. Applying gentle pressure can slow down the baby's descent and allow the perineum to stretch gradually, reducing the likelihood of severe tearing. This intervention is important to promote a safe and controlled delivery.
Incorrect answer explanations:
A: Applying warm compresses may provide some comfort but does not specifically address the need to support the perineum during childbirth.
C: Episiotomy should be considered only when necessary and not as a routine intervention when the perineum bulges.
D: Perineal massage is typically done during the prenatal period to help prepare the perineum for childbirth but is not the most appropriate intervention when the perineum starts to bulge during labor.