Nokea
Which interventions could a nurse apply to help stimulate contractions?
- A. Encouraging the patient to sit upright
- B. Assisting the patient to ambulate
- C. Stimulating the nipples
- D. Offering emotional support
- E. Allowing the patient to vent frustration
Correct Answer: A,B,C
Rationale: Sitting upright, ambulating, and stimulating the nipples may encourage progression of labor.
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What position will the nurse promote to encourage fetal rotation and pain relief?
- A. Prone with legs supported and give her a back massage
- B. Supine with legs bent at the knee
- C. Standing with support
- D. Sitting up and leaning forward on the overbed table
Correct Answer: D
Rationale: A position that favors fetal rotation and descent and is helpful for the woman with back labor is to sit or kneel leaning forward on a support.
What will the nurse include in the educational plan?
- A. Onset is slow.
- B. Duration is short.
- C. Administration is by mouth.
- D. No known side effects.
- E. It is not the same drug as sufentanil.
Correct Answer: B,E
Rationale: Fentanyl has a rapid onset and short duration of action. Fentanyl, sufentanil, and alfentanil are distinct drugs. Fentanyl can cause respiratory depression but less than meperidine and is not administered by mouth.
What is the nurse's initial action?
- A. Stop the oxytocin infusion.
- B. Continue the infusion and report the findings to the physician.
- C. Turn her on her left side and reassess the contractions.
- D. Administer oxygen by mask.
Correct Answer: A
Rationale: Oxytocin is discontinued if signs of fetal compromise or excessive uterine contractions occur.
What sign(s) of infection should the nurse assess for after an amniotomy?
- A. Oral temperature of 37?°C (99.8?°F)
- B. Increase of fetal heart rate (FHR) from 160 to 174 beats/minute
- C. Flecks of vernix in the amniotic fluid
- D. Low back pain
Correct Answer: B
Rationale: Increase in the FHR above 160 beats/minute frequently precedes a woman's temperature elevation, indicating possible infection.
What will the nurse expect when caring for this patient?
- A. Elevated uterine resting tone
- B. Painful and poorly coordinated contractions
- C. Implementation of fluid restriction
- D. Use of frequent position changes
Correct Answer: D
Rationale: A woman with hypotonic labor dysfunction will be encouraged to change position frequently to enhance contractions.