ATI RN
Promoting Client Comfort During Labor and Delivery Questions
Question 1 of 5
A multipara's labor plan includes the use of jet hydrotherapy during the active phase of labor. What is the priority patient assessment prior to assisting the patient with this request?
Correct Answer: B
Rationale: The correct answer is B: Maternal temperature. The priority assessment before using jet hydrotherapy is to check the maternal temperature to ensure it is within normal limits. Elevated temperature can indicate infection, which could be exacerbated by hydrotherapy. Maternal pulse (A), blood pressure (C), and blood glucose level (D) are important assessments but are not the priority before using hydrotherapy. Pulse and blood pressure can be monitored during hydrotherapy, and blood glucose levels are typically not affected by hydrotherapy.
Question 2 of 5
The nurse detects hypotension in a laboring patient after an epidural. Which actions should the nurse plan to implement? (SeNleUctRaSllIthNatGaTpBpl.y.)C OM
Correct Answer: C
Rationale: The correct answer is C: Administer a normal saline bolus as prescribed. In this scenario, hypotension post-epidural could be due to vasodilation leading to decreased blood pressure. Administering a normal saline bolus can help increase intravascular volume and improve blood pressure. Encouraging the patient to drink fluids (A) may not provide immediate volume resuscitation. Placing the patient in a Trendelenburg position (B) can worsen hypotension by increasing pressure on the vena cava. Administering oxygen (D) may be helpful but addressing the hypotension with a saline bolus is the priority.
Question 3 of 5
Excessive anxiety during labor heightens the patient's sensitivity to pain by increasing
Correct Answer: A
Rationale: The correct answer is A: muscle tension. Excessive anxiety can lead to increased muscle tension, which can amplify the perception of pain during labor. Tense muscles can make contractions feel more intense and uncomfortable. Increased anxiety does not directly affect the pain threshold (B), blood flow to the uterus (C), or rest time between contractions (D) in a way that would heighten sensitivity to pain. Thus, choice A is the most appropriate explanation for how anxiety impacts pain perception during labor.
Question 4 of 5
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?
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.
Question 5 of 5
The nurse is preparing a patient for a cesarean birth scheduled to be performed under general anesthesia. Which should the nurse plan to administer, if ordered by the health care provider, to prevent aspiration of gastric contents?
Correct Answer: C
Rationale: The correct answer is C: Hydroxyzine (Vistaril). Hydroxyzine is a first-generation antihistamine with antiemetic properties that can help reduce the risk of aspiration of gastric contents during general anesthesia. It works by decreasing nausea and vomiting, which in turn decreases the likelihood of aspiration. Citric acid (Bicitra) can actually increase gastric acidity and promote aspiration. Ranitidine (Zantac) is a histamine-2 receptor antagonist used to reduce gastric acid secretion but does not directly prevent aspiration. Glycopyrrolate (Robinul) is an anticholinergic medication used to reduce secretions but does not specifically target prevention of aspiration. Therefore, hydroxyzine is the most appropriate choice in this scenario.