Nokea
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.
You may also like to solve these questions
Which nursing action is most appropriate for a laboring patient experiencing severe back pain due to a posterior fetal position?
- A. Offer narcotic analgesics for pain relief.
- B. Encourage frequent position changes.
- C. Provide continuous fetal monitoring.
- D. Prepare the patient for an immediate cesarean delivery.
Correct Answer: B
Rationale: The correct answer is B: Encourage frequent position changes. This is because changing positions can help alleviate pressure on the back and potentially help the baby rotate into a more favorable position for delivery. It is a non-invasive and supportive approach to managing back pain during labor. Offering narcotic analgesics (choice A) may provide temporary relief but does not address the underlying issue. Continuous fetal monitoring (choice C) is important but not the most immediate intervention for back pain. Immediately preparing for a cesarean delivery (choice D) is not warranted unless there are other concerning factors beyond back pain.
A woman who is gravida 3, para 2 enters the intrapartum unit. The most important nursing assessments include
- A. contraction pattern, amount of discomfort, and pregnancy history.
- B. fetal heart rate, maternal vital signs, and the woman's nearness to birth.
- C. last food intake, when labor began, and cultural practices the couple desires.
- D. identification of ruptured membranes, the woman's gravida and para, and access to a support person.
Correct Answer: B
Rationale: The correct answer is B because fetal heart rate, maternal vital signs, and the woman's nearness to birth are crucial assessments in the intrapartum period. Fetal heart rate indicates fetal well-being, maternal vital signs reflect maternal status, and assessing the nearness to birth helps in determining the stage of labor and necessary interventions.
A is incorrect because while contraction pattern and discomfort are important, pregnancy history is not as immediate a concern in the intrapartum period.
C is incorrect as last food intake and cultural practices are not the most critical assessments during labor.
D is incorrect because while identification of ruptured membranes is important, the woman's gravida and para are less immediate concerns compared to fetal heart rate and maternal vital signs.
You are preparing a patient for epidural placement by a nurse anesthetist in the LDR. Which interventions should be included in the plan of care? (Select all that apply.)
- A. Administer a bolus of 500 to 1000 mL of D normal saline prior to catheter placement.
- B. Have ephedrine availableN aUt bR eSdsI idNeG duTrB in. g C caOthM eter placement.
- C. Monitor blood pressure of patient frequently during catheter insertion and for the first 15 minutes of epidural administration.
- D. Insert a Foley catheter prior to epidural catheter placement.
Correct Answer: A
Rationale: The correct answer is A because administering a bolus of 500 to 1000 mL of D5 normal saline prior to catheter placement helps prevent hypotension, a common side effect of epidural anesthesia. This bolus helps maintain adequate fluid volume, which is crucial for hemodynamic stability during the procedure.
Choice B is incorrect because having ephedrine available is not a necessary intervention for preparing a patient for epidural placement.
Choice C is incorrect because while monitoring blood pressure is important during epidural administration, it should be done continuously rather than just for the first 15 minutes.
Choice D is incorrect because inserting a Foley catheter is not a routine intervention for epidural catheter placement and is not directly related to the procedure's success or safety.
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.
The nurse is caring for a patient in transition. Which sign is most indicative that this phase of labor is occurring?
- A. Regular contractions every 3 minutes lasting 60 seconds.
- B. Increased bloody show and complaints of pressure.
- C. The urge to push with each contraction.
- D. Cervical dilation of 4 to 5 cm.
Correct Answer: B
Rationale: The correct answer is B because increased bloody show and complaints of pressure are indicative of the transition phase of labor. This phase occurs when the cervix dilates from 8 to 10 cm and contractions are strong and close together. This is a sign that the baby is moving down the birth canal. The other choices are incorrect because A describes the active phase of labor, C indicates the second stage of labor, and D reflects early labor. B is the most appropriate choice as it specifically aligns with the characteristics of the transition phase.