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Which of the following behaviors would be applicable to a nursing diagnosis of "risk for injury" in a patient who is in labor?
- A. Length of second-stage labor is 2 hours.
- B. Patient has received an epidural for pain control during the labor process.
- C. Patient is using breathing techniques during contractions to maximize pain relief.
- D. Patient is receiving parenteral fluids during the course of labor to maintain hydration.
Correct Answer: A
Rationale: The correct answer is A: Length of second-stage labor is 2 hours. This is applicable to the nursing diagnosis of "risk for injury" in a patient in labor because a prolonged second-stage labor can increase the risk of injury to both the mother and the baby. A prolonged second stage can lead to issues such as fetal distress, maternal exhaustion, and increased risk of instrumental delivery or cesarean section.
Explanation for why the other choices are incorrect:
B: Patient has received an epidural for pain control during the labor process - This choice does not directly address the risk for injury in labor.
C: Patient is using breathing techniques during contractions to maximize pain relief - While breathing techniques can help with pain relief, it does not specifically address the risk for injury.
D: Patient is receiving parenteral fluids during the course of labor to maintain hydration - While hydration is important during labor, it does not directly address the risk for injury.
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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.
The nurse is preparing a patient for a cesarean birth scheduled to be performed under general
- A. Which should the nurse plan to administer, if ordered by the health care provider, to prevent aspiration of gastric contents? (Select all that apply.)
- B. Citric acid (Bicitr
- C. Bromocriptine (Parlodel)
- D. Ranitidine (Zanta
Correct Answer: B
Rationale: The correct answer is B: Citric acid (Bicitr). Citric acid helps decrease the acidity of gastric contents, reducing the risk of aspiration during general anesthesia. Citric acid works as an antacid and helps neutralize stomach acid, which can help prevent complications during surgery.
Incorrect choices:
A: This choice is incorrect because it does not address the prevention of aspiration of gastric contents.
C: Bromocriptine is a medication used to treat conditions like hyperprolactinemia and Parkinson's disease. It is not indicated for preventing aspiration during surgery.
D: Ranitidine is an H2 blocker used to reduce stomach acid production. While it can help with heartburn and acid reflux, it is not typically used to prevent aspiration during surgery.
What is the expected effect of pudendal anesthesia?
- A. loss of sensation in the perineum
- B. decreased ability to move one's legs
- C. permanent loss of motor function
- D. loss of consciousness
Correct Answer: A
Rationale: The correct answer is A: loss of sensation in the perineum. Pudendal anesthesia specifically targets the pudendal nerve, which supplies sensation to the perineum. By blocking this nerve, the expected effect is a loss of sensation in the perineal region. Choices B, C, and D are incorrect because pudendal anesthesia does not affect motor function, consciousness, or the ability to move one's legs. It is important to understand the specific nerve being targeted and its function to determine the expected effects of anesthesia.
The nurse is providing care to a patient in the active phase of the first stage of labor. The patient is crying out loudly with each contraction. What is the nurse's most respectful approach for this patient?
- A. Ask the patient's labor coach if this is a usual expression of pain for her.
- B. Refer to the patient's chart to determine any orders for pain medication.
- C. Tell the patient that she is disturbing the other laboring patients on the unit.
- D. Encourage the patient to try to suppress her noisiness during contractions.
Correct Answer: A
Rationale: Step-by-step rationale for why Answer A is correct:
1. Asking the patient's labor coach shows respect for the patient's support person and acknowledges their insight into the patient's usual behavior.
2. It allows the nurse to gather information about the patient's pain expression without assuming or judging the situation.
3. This approach promotes patient-centered care and involves the patient's primary support system in decision-making.
4. It fosters open communication and partnership between the nurse, patient, and labor coach, enhancing the overall quality of care.
Summary:
- Option B is incorrect because pain medication should not be assumed without assessing the patient's current pain level first.
- Option C is incorrect as it lacks empathy and disregards the patient's emotional state during labor.
- Option D is incorrect as it suggests suppressing a natural response to pain, which may not be beneficial for the patient's coping mechanism.
The laboring person is in pain and very anxious. They do not want to use traditional pain relief methods. What can the nurse offer the laboring person to help with relaxation and reducing anxiety?
- A. lavender oil
- B. epidural
- C. nalbuphine hydrochloride (Nubain)
- D. cold rag
Correct Answer: A
Rationale: The correct answer is A: lavender oil. Lavender oil is a natural remedy known for its calming and relaxing properties, which can help reduce anxiety and promote relaxation in laboring individuals. It is safe and non-invasive, making it an ideal choice for someone who does not want traditional pain relief methods.
Incorrect choices:
B: Epidural is a commonly used pain relief method that involves injecting anesthesia into the epidural space, providing effective pain relief but not specifically targeting relaxation and anxiety reduction.
C: Nalbuphine hydrochloride (Nubain) is a synthetic opioid analgesic that can help manage pain but may not address the individual's desire for non-traditional methods.
D: Cold rag may provide some temporary relief for discomfort but may not be as effective in promoting relaxation and reducing anxiety compared to the calming effects of lavender oil.