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While assisting with a vacuum extraction birth, which alteration should the nurse immediately report to the obstetric provider?
- A. Maternal pulse rate of 100 bpm
- B. Maternal blood pressure of 120/70 mm Hg
- C. Persistent fetal bradycardia below 100 bpm
- D. Decreased intensity of uterine contractions
Correct Answer: C
Rationale: The correct answer is C: Persistent fetal bradycardia below 100 bpm. This is crucial because it indicates fetal distress and requires immediate intervention to prevent potential harm to the baby. Bradycardia below 100 bpm may indicate inadequate oxygen supply to the fetus, necessitating urgent action. Maternal vital signs in choices A and B are within normal ranges. Choice D, decreased intensity of uterine contractions, while important, is not as critical as fetal bradycardia in this scenario.
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The nurse receives orders for pharmacologic pain relief. What does the nurse explain to the laboring person after administering fentanyl?
- A. "I will need to monitor your oxygen saturation."
- B. "It's important for me to insert a Foley catheter."
- C. "I will need to monitor for vaginal bleeding."
- D. "It's important for me to check your cervix after I administer this medication."
Correct Answer: A
Rationale: Rationale: After administering fentanyl, the nurse explains the need to monitor oxygen saturation due to the potential respiratory depression as a side effect of the medication. This is crucial for early detection and intervention. Monitoring for vaginal bleeding (C) is unrelated to fentanyl administration. Inserting a Foley catheter (B) and checking the cervix (D) are not necessary post-fentanyl administration. Oxygen saturation monitoring is the priority for patient safety.
The nurse auscultates the fetal heart rate and determines a rate of 152 bpm. Which nursing intervention is most appropriate at this time?
- A. Inform the mother that the fetal heart rate is normal.
- B. Reassess the fetal heart rate in 5 minutes because the rate is too high.
- C. Report the fetal heart rate to the physician or nurse-midwife immediately.
- D. Suggest to the mother that she is going to have a boy because the heart rate is fast.
Correct Answer: C
Rationale: The correct answer is C: Report the fetal heart rate to the physician or nurse-midwife immediately. A fetal heart rate of 152 bpm is within the normal range for a fetus, but it is essential to communicate any findings to the healthcare provider for further assessment and monitoring. This step ensures the safety and well-being of both the mother and the fetus by allowing the healthcare provider to determine if any additional actions are necessary.
Incorrect choices:
A: Inform the mother that the fetal heart rate is normal - While the heart rate may be normal, it is crucial to involve the healthcare provider for proper evaluation.
B: Reassess the fetal heart rate in 5 minutes because the rate is too high - 152 bpm is not considered too high, and immediate reporting to the healthcare provider is necessary.
D: Suggest to the mother that she is going to have a boy because the heart rate is fast - Fetal heart rate is not a reliable indicator of the baby's gender, and this
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.
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 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.