A patient in active labor requests an epidural for pain management. What is the nurse's most appropriate intervention at this juncture?

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Promoting patient comfort during labor and birth questions quizlet Questions

Question 1 of 5

A patient in active labor requests an epidural for pain management. What is the nurse's most appropriate intervention at this juncture?

Correct Answer: C

Rationale: The correct answer is C: Determine the patient's contraction pattern for the next 30 minutes. This is the most appropriate intervention as understanding the patient's contraction pattern is crucial in determining the stage of labor and the need for interventions like epidural. Assessing fetal heart rate (A) is important but not the immediate priority. Taking blood pressure (B) every 5 minutes is excessive and not directly related to the request for an epidural. Initiating an IV infusion of lactated Ringer's solution (D) is unnecessary and not indicated for pain management in labor. In summary, choice C is correct as it directly addresses the patient's current condition and guides further pain management decisions.

Question 2 of 5

The nurse is preparing a patient for a cesarean birth scheduled to be performed under general

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.

Question 3 of 5

A patient in labor is approaching the transition stage and already has an epidural in place. An additional dose of medication has been prescribed and administered to the patient. Which priority intervention should be performed in order to evaluate the clinical response to treatment?

Correct Answer: B

Rationale: The correct answer is B. Document maternal blood pressure and fetal heart rates following medication administration and observe for any variations. This is because assessing maternal blood pressure and fetal heart rates can provide crucial information about the patient's response to the medication and the overall well-being of both the mother and the baby during labor. Any variations in these vital signs could indicate potential complications that need immediate attention. Choice A is not the priority as pain assessment, though important, may not provide immediate information on the effectiveness of the medication in this critical stage of labor. Choice C, documenting intake and output, is not as critical as monitoring vital signs in this scenario. Choice D is also not the priority as increasing fluid rate, though important for hydration, may not be the immediate concern in evaluating the clinical response to the medication.

Question 4 of 5

A patient presents to the labor and birth area for emergent birth. Vaginal exam reveals that the patient is fully dilated, vertex, +2 station, with ruptured membranes. The patient is extremely apprehensive because this is her first childbirth experience and asks for an epidural to be administered now. What is the priority nursing response based on this patient assessment?

Correct Answer: C

Rationale: The correct answer is C. In this scenario, the patient is fully dilated and at +2 station, indicating imminent birth. The priority nursing response should focus on assisting the patient with nonpharmacologic pain distraction methods as the birth is likely to occur soon. Nonpharmacologic pain management techniques such as breathing exercises, positioning changes, massage, and emotional support can help alleviate the patient's anxiety and provide comfort during this intense stage of labor. Administering an epidural at this late stage may not be feasible or effective due to the advanced stage of labor and imminent birth. Options A and D are not appropriate as they do not address the immediate needs of the patient in active labor. Option B is incorrect as it dismisses the patient's request for pain relief and fails to address her emotional and physical needs during labor.

Question 5 of 5

Which fetal position increases the likelihood of a longer and more painful labor?

Correct Answer: A

Rationale: The correct answer is A: Left occiput posterior. In this position, the baby's head is facing the mother's sacrum, making labor longer and more painful due to the baby's position causing more pressure on the mother's back and pelvis. Left occiput anterior (B) and Right occiput anterior (C) are favorable positions for a smoother labor. Right occiput transverse (D) can also lead to a longer and more complicated labor, but not as much as Left occiput posterior.

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