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Which patient will be most receptive to teaching about nonpharmacologic pain control methods?
- A. Gravida 1, para 0, in transition
- B. Gravida 2, para 1, admitted at 8 cm
- C. Gravida 1, para 0, dilated 2 cm, 80% effaced
- D. Gravida 3, para 2, complaining of intense perineal pressure
Correct Answer: C
Rationale: The correct answer is C because the patient is dilated at 2 cm and 80% effaced, indicating early labor. This stage allows for the patient to be receptive to learning about nonpharmacologic pain control methods. The other choices are incorrect because they are in active labor or experiencing intense pressure, making it less ideal for teaching nonpharmacologic methods.
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The nurse is caring for a patient in transition. Which sign is most indicative that this phase of labor is occurring?
- A. Regular contractions every 3 minutes lasting 60 seconds.
- B. Increased bloody show and complaints of pressure.
- C. The urge to push with each contraction.
- D. Cervical dilation of 4 to 5 cm.
Correct Answer: B
Rationale: The correct answer is B because increased bloody show and complaints of pressure are indicative of the transition phase of labor. This phase occurs when the cervix dilates from 8 to 10 cm and contractions are strong and close together. This is a sign that the baby is moving down the birth canal. The other choices are incorrect because A describes the active phase of labor, C indicates the second stage of labor, and D reflects early labor. B is the most appropriate choice as it specifically aligns with the characteristics of the transition phase.
A patient at 40 weeks' gestation should be instructed to go to a hospital or birth center for evaluation when she experiences
- A. increased fetal movement.
- B. irregular contractions for 1 hour.
- C. a trickle of fluid from the vagin
- D. thick pink or dark red vaginal mucus.
Correct Answer: C
Rationale: The correct answer is C because a trickle of fluid from the vagina at 40 weeks' gestation could indicate the rupture of membranes, which is a sign of impending labor. This warrants immediate evaluation to assess the status of the amniotic sac and the need for monitoring or intervention.
Explanation for other choices:
A: Increased fetal movement is a normal sign of fetal well-being and not a reason for immediate evaluation.
B: Irregular contractions for 1 hour may not necessarily indicate active labor, so immediate evaluation is not needed.
D: Thick pink or dark red vaginal mucus may indicate bloody show, which can be a sign of labor starting, but it is not as urgent as a potential rupture of membranes.
A woman who is gravida 3, para 2 enters the intrapartum unit. The most important nursing assessments include
- A. contraction pattern, amount of discomfort, and pregnancy history.
- B. fetal heart rate, maternal vital signs, and the woman's nearness to birth.
- C. last food intake, when labor began, and cultural practices the couple desires.
- D. identification of ruptured membranes, the woman's gravida and para, and access to a support person.
Correct Answer: B
Rationale: The correct answer is B because fetal heart rate, maternal vital signs, and the woman's nearness to birth are crucial assessments in the intrapartum period. Fetal heart rate indicates fetal well-being, maternal vital signs reflect maternal status, and assessing the nearness to birth helps in determining the stage of labor and necessary interventions.
A is incorrect because while contraction pattern and discomfort are important, pregnancy history is not as immediate a concern in the intrapartum period.
C is incorrect as last food intake and cultural practices are not the most critical assessments during labor.
D is incorrect because while identification of ruptured membranes is important, the woman's gravida and para are less immediate concerns compared to fetal heart rate and maternal vital signs.
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.
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.