Nokea
Which activity should the nurse recommend to prepare for labor?
- A. Practicing relaxation and breathing techniques
- B. Increasing caffeine intake
- C. Avoiding all physical activity
- D. Taking daily hot baths
Correct Answer: A
Rationale: Practicing relaxation and breathing techniques helps manage labor pain and prepares the client for childbirth.
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The client in labor is requesting water therapy (hydrotherapy) to help provide pain relief and relaxation. Her recent vaginal exam was 2/50/—2. How should the nurse respond to the client’s request?
- A. “Usually we initiate hydrotherapy during active labor.”
- B. “You will not need to change positions quite as much.”
- C. “We will not be able to monitor fetal heart rate as easily.”
- D. “You can use hydrotherapy for up to 60 minutes at a time.”
Correct Answer: A
Rationale: Hydrotherapy is usually initiated when the client is in active labor, at approximately 4 or 5 cm. This timing will help reduce the risk of prolonged labor and provide a welcome change when the contractions are becoming stronger and closer together. Changing position takes less effort while immersed in water, so women are encouraged to change positions more frequently to help facilitate the process of labor. FHR monitoring can be done just as easily during hydrotherapy, using a wireless external monitor, Doppler, or fetoscope. Internal electrodes can be placed during most types of hydrotherapy but is contraindicated during jet hydrotherapy. There is no time limit for laboring women to use hydrotherapy; they may stay as long as desired, unless complications develop during the labor process.
The continuous electronic FHR monitor tracing on the laboring client is no longer recording. How should the nurse immediately respond?
- A. Conclude that there is a problem with the baby and call for help.
- B. Check that there is adequate gel under the transducer and reposition.
- C. Give the client oxygen via facemask at 8 to 10 liters per minute.
- D. Auscultate fetal heart rate by fetoscope and assess maternal vital signs.
Correct Answer: B
Rationale: When the FHR monitor tracing is no longer recording, the nurse should first check for adequate gel under the transducer. There needs to be adequate gel under the transducer for good conduction, and adding gel frequently corrects the problem. Assessing for adequate gel under the transducer and repositioning should be done before assuming there is a problem with the baby’s HR. There is no indication to give oxygen to the client. Auscultating FHR by fetoscope and assessing maternal VS could be completed, but not until the transducer has been checked.
The client delivered a healthy newborn 4 hours ago after being induced with oxytocin. While being assisted to the bathroom to void for the first time after delivery, the client tells the nurse that she doesn’t feel a need to urinate. Which explanation should the nurse provide when the client expresses surprise after voiding 900 mL of urine?
- A. “A decreased sensation of bladder filling is normal after childbirth.”
- B. “The oxytocin you received in labor makes it difficult to feel voiding.”
- C. “You probably didn’t empty completely. I will need to scan your bladder.”
- D. “Your bladder capacity is large; you likely won’t void again for 6—8 hours.”
Correct Answer: A
Rationale: The nurse should explain about the decreased sensation of bladder filling after childbirth. It is not uncommon for the postpartum client to have increased bladder capacity, decreased sensitivity to fluid pressure, and a decreased sensation of bladder filling. Oxytocin (Pitocin) is not expected to cause a change in bladder sensation, but it does have an antidiuretic effect. There is no indication that the client didn’t completely empty; a volume of 900 mL is a large amount. The postpartum client is at risk for bladder overdistention and should be encouraged to void every 2 to 4 hours.
How many factors in this scenario place the client at risk for nutritional deficiencies and the need for dietary guidance and counseling?
- A. Three
- B. Four
- C. Five
- D. Six
Correct Answer: C
Rationale: Five risk factors: adolescence, skipping meals, fast food diet, alcohol consumption, and weight gain concerns increase nutritional deficiency risk.
The postpartum client, who had a forceps-assisted vaginal birth 4 hours ago, tells the nurse that she is having continuing perineal pain rated at 7 out of 10 and rectal pressure. An oral analgesic was given and ice applied to the perineum earlier. What should the nurse do now?
- A. Call the HCP to report the pain
- B. Closely reinspect the perineum
- C. Help her out of bed to ambulate
- D. Administer a stool softener
Correct Answer: B
Rationale: Reexamination of the perineum should be completed before calling the HCP to report the pain level. A forceps-assisted delivery can increase the risk of hematoma development. Rectal pressure and perineal pain can indicate a hematoma in the posterior vaginal wall. The nurse should closely examine the perineum and the vaginal introitus for ecchymosis and a bulging mass. Ambulation would not help the perineal pain. A stool softener would be appropriate to avoid constipation but would not help the immediate problem.