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What is the term for a slow, deep inhalation through the nose and exhalation through the mouth before a contraction for preparation and after a contraction for release of tension from the contraction?
- A. pursed-lip breathing
- B. panting
- C. chanting
- D. cleansing breath
Correct Answer: D
Rationale: The correct answer is D: cleansing breath. This technique involves slow, deep inhalation through the nose and exhalation through the mouth to release tension. Pursed-lip breathing (A) is used for managing shortness of breath. Panting (B) is rapid, shallow breathing. Chanting (C) involves rhythmic speaking or singing. Cleansing breath (D) fits the description best as it focuses on deep, intentional breathing for relaxation and release of tension before and after a contraction.
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The labor nurse is developing a plan of care for a patient admitted in active labor with
- A. On admission, vital signs were as follows: maternal heart rate (HR) 92 bpm; fetal rate (FHR) baseline, 150 to 160 bpm; blood pressure, 124/76 mm Hg; temperature 37.2° C (99° F). What is the priority nursing action for this patient?
- B. Fetal acoustic stimulation
- C. Assess temperature everyN 2 hRourIs G
- D. Change absorption pads under her hips every 2 hours
Correct Answer: A
Rationale: The correct answer is A: On admission, vital signs were as follows: maternal heart rate (HR) 92 bpm; fetal rate (FHR) baseline, 150 to 160 bpm; blood pressure, 124/76 mm Hg; temperature 37.2° C (99° F). The priority nursing action for this patient is to assess the vital signs. The maternal heart rate, fetal heart rate, blood pressure, and temperature are crucial indicators of the patient's and the fetus's well-being during labor. Monitoring these vital signs helps the nurse detect any abnormalities or signs of distress promptly, allowing for timely intervention.
Choice B, fetal acoustic stimulation, is not the priority at this stage as there are no indications in the question stem that suggest the need for this intervention. Choice C, assessing temperature every 2 hours, is not the priority as the patient's temperature is within normal range on admission. Choice D, changing absorption pads under her hips every 2 hours,
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.
What nursing intervention can be performed prior to epidural placement to potentially reduce a blood pressure drop?
- 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: The correct answer is B: IV fluid bolus. Prior to epidural placement, administering an IV fluid bolus can help prevent a drop in blood pressure by increasing preload and maintaining cardiac output. This helps offset the vasodilation effects of the epidural anesthesia. Options A, C, and D are incorrect. Ephedrine (A) is not routinely used before epidural placement due to its potential adverse effects. Insertion of a urinary catheter (C) is not directly related to preventing a blood pressure drop. Upright positioning (D) may actually worsen hypotension by pooling blood in the lower extremities.
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.
Which of the following factors would affect pain perception or tolerance for the laboring patient?
- A. Right occiput posterior fetal position during labor
- B. Bishop score of 10 prior to the induction of labor
- C. Gynecoid pelvis
- D. Absence of Ferguson's reflex
Correct Answer: A
Rationale: The correct answer is A: Right occiput posterior fetal position during labor. This position can lead to intense back pain and prolonged labor, affecting pain perception. A posterior position can put pressure on the sacrum and cause increased discomfort. In contrast, choices B, C, and D do not directly impact pain perception during labor. Choice B, Bishop score of 10, indicates favorable conditions for labor progress but does not necessarily affect pain perception. Choice C, Gynecoid pelvis, refers to a common pelvis shape that may facilitate labor but does not directly influence pain tolerance. Choice D, Absence of Ferguson's reflex, is related to the ability to push effectively but is not directly linked to pain perception.