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Which assessment would be important for a 6-hour-old infant who has bruising over the cheeks from a forceps birth?
- A. Presence of newborn reflexes
- B. Symmetry of facial movements
- C. Caput and molding of the head
- D. Anterior and posterior fontanels
Correct Answer: B
Rationale: The correct answer is B: Symmetry of facial movements. Bruising over the cheeks can indicate potential nerve damage from the forceps birth. Assessing facial movements helps determine if there is any nerve injury affecting facial muscles. Presence of newborn reflexes (A) is important but not directly related to facial nerve injury. Caput and molding of the head (C) are more related to the birthing process and not specific to facial nerve assessment. Anterior and posterior fontanels (D) are important for assessing fontanelle closure but not specific to facial nerve evaluation.
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The nurse is preparing a patient for a cesarean birth scheduled to be performed under general anesthesia. Which should the nurse plan to administer, if ordered by the health care provider, to prevent aspiration of gastric contents?
- A. Citric acid (Bicitra)
- B. Ranitidine (Zantac)
- C. Hydroxyzine (Vistaril)
- D. Glycopyrrolate (Robinul)
Correct Answer: C
Rationale: The correct answer is C: Hydroxyzine (Vistaril). Hydroxyzine is a first-generation antihistamine with antiemetic properties that can help reduce the risk of aspiration of gastric contents during general anesthesia. It works by decreasing nausea and vomiting, which in turn decreases the likelihood of aspiration. Citric acid (Bicitra) can actually increase gastric acidity and promote aspiration. Ranitidine (Zantac) is a histamine-2 receptor antagonist used to reduce gastric acid secretion but does not directly prevent aspiration. Glycopyrrolate (Robinul) is an anticholinergic medication used to reduce secretions but does not specifically target prevention of aspiration. Therefore, hydroxyzine is the most appropriate choice in this scenario.
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.
Excessive anxiety during labor heightens the patient's sensitivity to pain by increasing
- A. muscle tension.
- B. the pain threshold.
- C. blood flow to the uterus.
- D. rest time between contractions.
Correct Answer: A
Rationale: The correct answer is A: muscle tension. Excessive anxiety can lead to increased muscle tension, which can amplify the perception of pain during labor. Tense muscles can make contractions feel more intense and uncomfortable. Increased anxiety does not directly affect the pain threshold (B), blood flow to the uterus (C), or rest time between contractions (D) in a way that would heighten sensitivity to pain. Thus, choice A is the most appropriate explanation for how anxiety impacts pain perception during labor.
The nurse is preparing to initiate intravenous (IV) access on a patient in the active phase of labor. Which size IV cannula is best for this patient?
- A. 18-gauge
- B. 20-gauge
- C. 22-gauge
- D. 24-gauge
Correct Answer: B
Rationale: The correct answer is B: 20-gauge. During active labor, a larger IV cannula is recommended to accommodate rapid fluid administration and potential blood loss. A 20-gauge cannula provides a good balance between flow rate and patient comfort. An 18-gauge cannula (choice A) may be too large and cause discomfort, while 22-gauge (choice C) and 24-gauge (choice D) may not allow for adequate fluid administration in a timely manner.
What technique, usually reserved for low-risk persons, has been shown to decrease pain, encourage movement, decrease anxiety, shorten labor, and improve labor satisfaction?
- A. controlled breathing
- B. aromatherapy
- C. massage
- D. hydrotherapy
Correct Answer: D
Rationale: The correct answer is D: hydrotherapy. Hydrotherapy involves the use of water for pain relief and relaxation during labor. It helps decrease pain by providing buoyancy and reducing the pressure on joints. The warm water encourages movement and relaxation, which can shorten labor duration and improve satisfaction. Controlled breathing (A) can be helpful but may not provide the same physical benefits as hydrotherapy. Aromatherapy (B) may help with relaxation but does not have the same direct physical effects on pain and movement. Massage (C) can be beneficial, but hydrotherapy offers a more comprehensive approach to pain management and labor support.