Promoting Client Comfort During Labor and Delivery

Promoting Client Comfort During Labor and Delivery Related

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Which nursing diagnosis would take priority in the care of a primipara patient with no visible support person in attendance? The patient has entered the second stage of labor after a first stage of labor lasting 4 hours.

  • A. Fluid volume deficit (FV
  • B. related to fluid loss during labor and birth process
  • C. Fatigue related to length of labor requiring increased energy expenditure
  • D. Acute pain related to increased intensity of contractions
Correct Answer: A

Rationale: The correct answer is A: Fluid volume deficit (FV) related to fluid loss during labor and birth process. This diagnosis takes priority because dehydration can lead to serious complications for the mother and the baby. Inadequate fluid intake during labor can result in decreased blood volume, affecting both maternal and fetal circulation. This can lead to fetal distress and maternal hypotension.

Choice B, fatigue related to length of labor, is important but not as critical as fluid volume deficit, as addressing dehydration is more urgent to prevent complications. Choice C, acute pain related to increased intensity of contractions, is also important but can be managed with pain relief measures, whereas fluid volume deficit requires immediate action. Therefore, it is not the priority at this moment.

In summary, addressing fluid volume deficit is the priority as it directly impacts the well-being of both the mother and the baby during labor and birth, while the other options can be addressed once the dehydration issue is resolved.

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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: B

Rationale: The correct answer is B: Naloxone (Narcan). Meperidine is an opioid analgesic that can cross the placenta and potentially cause respiratory depression in the newborn if given close to delivery. Naloxone is a specific opioid antagonist that can reverse the effects of opioids like meperidine quickly and effectively. Administering naloxone in this scenario can help prevent or reverse neonatal respiratory depression.

Choice A: Oxytocin (Pitocin) is not required in this scenario as it is used to induce or augment labor, not to counter the effects of meperidine.

Choice C: Bromocriptine (Parlodel) is a medication used to suppress lactation and is not indicated in this situation.

Choice D: Oxygen may be needed during delivery for maternal or fetal distress, but it is not the specific medication needed to counter the effects of meperidine in the newborn.

The nurse thoroughly dries the infant immediately after birth primarily to

  • A. reduce heat loss from evaporation.
  • B. stimulate crying and lung expansion.
  • C. increase blood supply to the hands and feet.
  • D. remove maternal blood from the skin surfac
Correct Answer: A

Rationale: The correct answer is A because drying the infant helps reduce heat loss through evaporation, preventing hypothermia. Wet skin can lead to rapid heat loss. This is critical for newborns who are at risk of temperature instability.

Choice B is incorrect because drying the infant is not primarily done to stimulate crying and lung expansion. Choice C is incorrect because drying does not increase blood supply to the hands and feet. Choice D is incorrect because maternal blood is typically cleared from the infant's skin through other means, not primarily by drying.

The best time to teach nonpharmacologic pain control methods to an unprepared laboring patient is during which stage?

  • A. Latent phase
  • B. Active phase
  • C. Second stage
  • D. Transition phase
Correct Answer: A

Rationale: The correct answer is A: Latent phase. This stage is ideal for teaching nonpharmacologic pain control methods as the patient is usually more receptive, relaxed, and able to focus. During the latent phase, contractions are typically mild and irregular, allowing the patient to learn and practice techniques effectively. In contrast, the active phase (choice B) is characterized by increased intensity and frequency of contractions, making it challenging for the patient to concentrate on learning. The second stage (choice C) is the pushing stage, where the focus shifts to pushing efforts rather than learning new techniques. The transition phase (choice D) is the most intense stage of labor, making it difficult for the patient to absorb and apply nonpharmacologic pain control methods effectively.

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.

You are preparing a patient for epidural placement by a nurse anesthetist in the LDR. Which interventions should be included in the plan of care? (Select all that apply.)

  • A. Administer a bolus of 500 to 1000 mL of D normal saline prior to catheter placement.
  • B. Have ephedrine availableN aUt bR eSdsI idNeG duTrB in. g C caOthM eter placement.
  • C. Monitor blood pressure of patient frequently during catheter insertion and for the first 15 minutes of epidural administration.
  • D. Insert a Foley catheter prior to epidural catheter placement.
Correct Answer: A

Rationale: The correct answer is A because administering a bolus of 500 to 1000 mL of D5 normal saline prior to catheter placement helps prevent hypotension, a common side effect of epidural anesthesia. This bolus helps maintain adequate fluid volume, which is crucial for hemodynamic stability during the procedure.

Choice B is incorrect because having ephedrine available is not a necessary intervention for preparing a patient for epidural placement.

Choice C is incorrect because while monitoring blood pressure is important during epidural administration, it should be done continuously rather than just for the first 15 minutes.

Choice D is incorrect because inserting a Foley catheter is not a routine intervention for epidural catheter placement and is not directly related to the procedure's success or safety.

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