ATI RN
Promoting patient comfort during labor and birth questions quizlet Questions
Question 1 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 2 of 5
During labor, a patient using hydrotherapy reports feeling faint. What is the nurse's priority intervention?
Correct Answer: A
Rationale: The correct answer is A: Remove the patient from the water. This is the priority intervention because the patient's safety is at risk due to feeling faint. Removing the patient from the water helps prevent potential drowning or injury. Increasing room temperature (choice B) may worsen the patient's condition by increasing heat stress. Providing additional fluids orally (choice C) may not address the immediate risk of fainting. Notifying the physician immediately (choice D) is important, but ensuring the patient's safety by removing them from the water takes precedence.
Question 3 of 5
A patient in active labor asks about using a birth ball. What is the primary benefit of using a birth ball during labor?
Correct Answer: B
Rationale: The correct answer is B: Helps maintain proper fetal alignment. Using a birth ball during labor helps the mother maintain an upright position, which can aid in proper alignment of the fetus for an optimal birthing position. This can facilitate the progress of labor and potentially reduce the risk of complications. A: Provides a distraction from labor pain - While using a birth ball may offer some distraction, the primary benefit is not pain management. C: Increases the rate of cervical dilation - While movement and positioning can support the body's natural labor process, the birth ball itself does not directly increase cervical dilation rate. D: Reduces the likelihood of epidural anesthesia use - While movement and positioning can sometimes help manage pain and reduce the need for epidural anesthesia, the primary benefit of the birth ball is more related to fetal alignment than pain management.
Question 4 of 5
During a vaginal exam, the nurse identifies that the fetal station is at +2. What does this finding indicate?
Correct Answer: C
Rationale: The correct answer is C because when the fetal station is at +2, it indicates that the presenting part is below the ischial spines. This means the baby's head is 2 cm below the ischial spines, which is a significant milestone in the descent of the fetus through the birth canal. The other choices are incorrect because: A) +2 station indicates descent, not that the fetus is high in the pelvis; B) Ischial spines are at 0 station, not +2; D) Crowning is at +5 station, not +2.
Question 5 of 5
A laboring patient experiences a sudden rupture of membranes and the nurse observes a prolapsed cord. What is the nurse's priority action?
Correct Answer: A
Rationale: The correct answer is A: Reposition the patient to relieve pressure on the cord. This is the priority action because a prolapsed cord can lead to fetal compromise due to decreased blood flow. By repositioning the patient to a knee-chest or Trendelenburg position, gravity helps alleviate pressure on the cord. This action is crucial to prevent further compromise to the fetus. Incorrect Choices: B: Immediately prepare the patient for a cesarean delivery - While this may be necessary eventually, the immediate priority is to relieve pressure on the cord. C: Administer oxygen at 10 L/min - Oxygen may be needed, but it is not the priority action in this emergency situation. D: Monitor the fetal heart rate continuously - Monitoring is important, but repositioning the patient to relieve cord compression takes precedence.