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Which comfort measure should the nurse utilize in order to enable a laboring woman to relax?
- A. Recommend frequent position changes.
- B. Palpate her filling bladder every 15 minutes.
- C. Offer warm wet cloths toN useR on Ithe GpatiBen.t'Cs faMce and neck. U S N T O
- D. Keep the room lights lit so the patient and her coach can see everything.
Correct Answer: C
Rationale: The correct answer is C because offering warm wet cloths to place on the patient's face and neck can help promote relaxation by providing a soothing sensation. This measure can help to reduce stress and tension, creating a calming environment for the laboring woman.
A: Recommending frequent position changes can help with labor progress and comfort, but it may not specifically address relaxation.
B: Palpating the filling bladder every 15 minutes is important for monitoring urinary output, but it is not a direct comfort measure for relaxation.
D: Keeping the room lights lit may be necessary for visibility, but bright lights can be distracting and may hinder relaxation.
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A patient presents to the labor and birth area for emergent birth. Vaginal exam reveals that the patient is fully dilated, vertex, +2 station, with ruptured membranes. The patient is extremely apprehensive because this is her first childbirth experience and asks for an epidural to be administered now. What is the priority nursing response based on this patient assessment?
- A. Use contact anesthesia for an epidural and prepare the patient per protocol.
- B. Tell the patient that she will not need any pain medication because the birth will be over in a matter of minutes and the pain will stop.
- C. Assist the patient with nonpharmacologic methods of pain distraction during this time as you prepare for vaginal birth.
- D. Call the physician for admitting orders.
Correct Answer: C
Rationale: The correct answer is C. In this scenario, the patient is fully dilated and at +2 station, indicating imminent birth. The priority nursing response should focus on assisting the patient with nonpharmacologic pain distraction methods as the birth is likely to occur soon. Nonpharmacologic pain management techniques such as breathing exercises, positioning changes, massage, and emotional support can help alleviate the patient's anxiety and provide comfort during this intense stage of labor. Administering an epidural at this late stage may not be feasible or effective due to the advanced stage of labor and imminent birth. Options A and D are not appropriate as they do not address the immediate needs of the patient in active labor. Option B is incorrect as it dismisses the patient's request for pain relief and fails to address her emotional and physical needs during labor.
The fetus is in an occiput posterior position. What position can the nurse assist the laboring person into that may encourage the fetus to find the occiput anterior position?
- A. squatting
- B. shower
- C. hands and knees
- D. semi-Fowler
Correct Answer: C
Rationale: The correct answer is C: hands and knees. This position can help rotate the fetus from occiput posterior to occiput anterior by allowing gravity to assist in the rotation. Placing the laboring person on hands and knees can help the baby's head shift towards the front, facilitating a more optimal birthing position. Squatting and shower may provide comfort but may not directly encourage the fetus to rotate. Semi-Fowler position may not be as effective in promoting the desired fetal positioning compared to hands and knees.
A patient who is receiving oxytocin (Pitocin) infusion for the augmentation of labor is
- A. Which intervention would be a priority?
- B. Increase rate of Pitocin infusion to help spread out contraction pattern.
- C. Place oxygen on patient at 8 to 10 L/minute via face mask and turn patient to left
- D. Stop Pitocin infusion.
Correct Answer: A
Rationale: The correct answer is A because the priority intervention for a patient receiving oxytocin infusion for labor augmentation is to monitor fetal heart rate and uterine contractions. This is essential to ensure the safety of both the mother and the baby. Increasing the rate of Pitocin infusion (B) can lead to hyperstimulation and fetal distress. Providing oxygen and changing position (C) may be helpful in some situations but are not the priority. Stopping the Pitocin infusion (D) should only be done if there are signs of fetal distress or other complications.
The pregnant patient expresses a desire to schedule birth during the baby's father's furlough
- A. The nurse explains that prior to induction of labor, it is essential to determine which clinical finding?
- B. Dilated cervix
- C. Fetal lung maturity
- D. Rupture of membranes
Correct Answer: C
Rationale: The correct answer is C: Fetal lung maturity. It is essential to determine fetal lung maturity before induction of labor to ensure that the baby's lungs are developed enough to breathe outside the womb. This is important for the baby's well-being and can help prevent complications.
Rationale:
1. Fetal lung maturity is crucial for the baby's ability to breathe independently.
2. Inducing labor without ensuring fetal lung maturity can lead to respiratory distress syndrome in the newborn.
3. A dilated cervix is important for labor progression but does not directly impact the baby's lung maturity.
4. Rupture of membranes may indicate potential labor but does not address the baby's lung development.
The nerve block used in labor that provides anesthesia to the lower vagina and perineum is referred to as a(n)
- A. local.
- B. epidural.
- C. pudendal.
- D. spinal block.
Correct Answer: C
Rationale: The correct answer is C: pudendal. Pudendal nerve block is specifically used to provide anesthesia to the lower vagina and perineum during labor. This block targets the pudendal nerve, which innervates these areas, providing effective pain relief for childbirth.
A local anesthetic is more general and may not specifically target the lower vagina and perineum. Epidural anesthesia is typically used to provide pain relief during labor but does not specifically target the lower vagina and perineum. A spinal block provides anesthesia for a larger area including the lower abdomen and legs, not specifically the lower vagina and perineum.