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When caring for a patient in labor who is considered to be at low risk, which assessments should be included in the plan of care? (Select all that apply.)
- A. Check the DTR each shift.
- B. Monitor and record vital signs frequently during the course of labor.
- C. Document the FHR pattern, noting baseline and response to contraction patterns.
- D. Indicate on the EFM tracing when maternal position changes are don
Correct Answer: B
Rationale: The correct answer is B: Monitor and record vital signs frequently during the course of labor. This is essential to ensure the patient's physiological stability and detect any deviations that may indicate complications. Checking the DTR (Choice A) is not relevant for low-risk patients in labor. Documenting the FHR pattern (Choice C) is important, but not as crucial as monitoring vital signs. Indicating maternal position changes on the EFM tracing (Choice D) is beneficial but not a priority assessment for low-risk patients. Vital sign monitoring is the most critical assessment for ensuring the well-being of the patient in labor.
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The laboring person is using hypnosis for comfort measures. How can the nurse support the person?
- A. Talk them through the contractions.
- B. Keep the lights on so that everyone can see.
- C. Keep the room quiet and dimly lit.
- D. During the contraction, ask them to rate the pain.
Correct Answer: C
Rationale: The correct answer is C because keeping the room quiet and dimly lit promotes relaxation and helps the person stay focused during hypnosis. Bright lights and noise can be distracting and increase stress levels. Talking them through contractions (Choice A) may disrupt their concentration on hypnosis. Asking them to rate pain during contractions (Choice D) can also be disruptive and may increase anxiety.
The nurse is preparing to perform Leopold's maneuvers. Please select the rationale for the consistent use of these maneuvers by obstetric providers?
- A. To determine the status of the membranes
- B. To determine cervical dilation and effacement
- C. To determine the best location to assess the fetal heart rate
- D. To determine whether the fetus is in the posterior position
Correct Answer: C
Rationale: The correct answer is C because Leopold's maneuvers are used to determine the best location to assess the fetal heart rate. Step 1: Palpate the fundus to identify the fetal part. Step 2: Determine the fetal back to locate the fetal heart sounds. Step 3: Identify the presenting part. Step 4: Determine the position of the fetal head. This systematic approach helps assess fetal well-being. Choices A and B are incorrect because Leopold's maneuvers focus on fetal position and presentation, not membrane status or cervical dilation. Choice D is incorrect as it pertains to the fetal position, which is not the primary purpose of Leopold's maneuvers.
A labor patient, gravida 2, para 1, at term has received meperidine (Demerol) for pain control during labor. Her most recent dose was 15 minutes ago and birth is now imminent. Maternal vital signs have been stable and the EFM tracing has not shown any baseline changes. Which medication does the nurse anticipate would be required in the birth room for administration?
- A. Oxytocin (Pitocin)
- B. Naloxone (Narcan)
- C. Bromocriptine (Parlodel)
- D. Oxygen
Correct Answer: A
Rationale: Rationale: The correct answer is A: Oxytocin (Pitocin). Oxytocin is commonly given during the third stage of labor to help with uterine contractions and prevent postpartum hemorrhage. Meperidine can cross the placenta and cause respiratory depression in the newborn. Therefore, the nurse should anticipate needing oxytocin to assist with contractions after birth to minimize bleeding.
Summary of other choices:
B: Naloxone (Narcan) - This is an opioid antagonist used to reverse the effects of opioids like meperidine. However, it is not typically needed if the newborn does not show signs of respiratory depression.
C: Bromocriptine (Parlodel) - This medication is not commonly used during labor and birth and is not indicated in this scenario.
D: Oxygen - While oxygen may be needed for the mother or newborn in certain situations, it is not directly related to the administration of meperidine or
A nurse is assisting a laboring patient with breathing techniques to reduce labor pain. Which technique involves exhaling slowly while concentrating on relaxing each muscle group?
- A. Cleansing breaths
- B. Slow-paced breathing
- C. Modified-paced breathing
- D. Effleurage
Correct Answer: B
Rationale: The correct answer is B: Slow-paced breathing. This technique involves exhaling slowly while focusing on relaxing each muscle group, which helps reduce labor pain. Slow-paced breathing promotes relaxation and reduces stress, making it an effective pain management technique during labor. Cleansing breaths (A) focus on deep breathing to clear the mind, not necessarily on muscle relaxation. Modified-paced breathing (C) involves breathing in a controlled pattern but may not specifically target muscle relaxation. Effleurage (D) is a massage technique involving light stroking movements, not breathing techniques for pain management.
The nurse is teaching a childbirth education class. Which information regarding excessive pain in labor should the nurse include in the session?
- A. It usually results in a more rapid labor.
- B. It has no effect on the outcome of labor.
- C. It is considered to be a normal occurrenc
- D. It may result in decreased placental perfusion.
Correct Answer: D
Rationale: The correct answer is D because excessive pain in labor can lead to increased maternal stress, which may result in decreased placental perfusion, compromising oxygen and nutrient delivery to the fetus. This can have serious implications for the baby's well-being. Choices A, B, and C are incorrect because excessive pain in labor does not necessarily lead to a more rapid labor, has an effect on the labor outcome by potentially impacting placental perfusion, and is not considered a normal occurrence that should be disregarded.