ATI RN
Comfort During Labor Questions
Question 1 of 5
A woman is in the second stage of labor with a strong urge to push. Which of the following actions by the nurse is appropriate at this time?
Correct Answer: B
Rationale: During the second stage of labor, the woman experiences strong contractions and an urge to push as the baby descends through the birth canal. Option A, assessing the fetal heart rate between contractions every 60 minutes, is incorrect because during the second stage of labor, fetal heart rate should be monitored continuously to ensure the well-being of the baby. Waiting 60 minutes between assessments could lead to missed signs of fetal distress. Option C, assessing the pulse and respirations of the mother every 5 minutes, is also incorrect. While it is essential to monitor the mother's vital signs, checking them every 5 minutes may not be necessary unless there are signs of distress or complications. Continuous monitoring is not typically required during the second stage of labor unless there are specific concerns. Option D, positioning the woman on her back with her knees on her chest, is not appropriate during the second stage of labor. This position, known as the lithotomy position, can actually impede the progress of labor by reducing the size of the pelvic outlet and increasing the risk of perineal trauma. It is more beneficial for the woman to be in an upright or semi-recumbent position that allows gravity to assist in the descent of the baby. Encouraging the woman to grunt during contractions, as stated in option B, is the correct action for the nurse to take during the second stage of labor. Grunting can help the woman focus her pushing efforts effectively, prevent her from pushing too forcefully, and conserve her energy for the duration of labor. This technique can also help prevent perineal trauma and promote a controlled delivery of the baby.
Question 2 of 5
A woman is in the transition phase of labor. Which of the following comments should the nurse expect to hear?
Correct Answer: B
Rationale: During the transition phase of labor, which is the most intense phase before pushing, the woman is likely to experience significant pain and discomfort due to strong and frequent contractions. Choice B, "I can't stand this pain any longer," is the correct answer because it reflects the expected response during this phase. The woman is likely to express feelings of being overwhelmed by the pain and may find it difficult to cope. Choice A, "I am so excited to be in labor," is incorrect because the transition phase is typically not a time of excitement but rather a time of intense focus and discomfort as the body prepares for the final stage of labor. Choice C, "I need ice chips because I'm so hot," is incorrect because the need for ice chips to cool down is not typically associated with the transition phase of labor. The focus during this phase is more on managing the pain and preparing for delivery. Choice D, "I have to push the baby out right now," is incorrect because the urge to push usually comes later in the labor process during the second stage, after the cervix is fully dilated. In the transition phase, the woman may feel an intense pressure but may not be fully dilated yet, so pushing prematurely can be harmful. In conclusion, the correct answer is B because it accurately reflects the expected experience of intense pain and discomfort during the transition phase of labor.
Question 3 of 5
A nurse concludes that a woman is in the latent phase of labor. Which of the following signs/symptoms would lead a nurse to that conclusion?
Correct Answer: A
Rationale: During the latent phase of labor, contractions are typically mild to moderate in intensity and occur at regular intervals. Choice A is correct because if the woman is able to talk and laugh during contractions, it indicates that her contractions are not yet intense or close enough together to signify active labor. This aligns with the characteristics of the latent phase. Choice B is incorrect because complaining about severe back labor is more indicative of active labor, where contractions are stronger and more frequent. This symptom is not typically associated with the latent phase of labor. Choice C is incorrect because performing effleurage (light circular stroking of the abdomen) during a contraction is a coping mechanism often used in active labor to help manage pain. In the latent phase, contractions are usually not intense enough to necessitate coping techniques like effleurage. Choice D is incorrect because the urge to defecate is more commonly associated with the later stages of labor as the baby descends and puts pressure on the rectum. In the latent phase, the woman is typically still able to walk around and may not yet feel the urge to bear down. In summary, the ability to talk and laugh during contractions is a key characteristic of the latent phase of labor, making choice A the correct answer. Choices B, C, and D are all more indicative of active labor or the later stages of labor, making them incorrect in this context.
Question 4 of 5
Which of the following actions would the nurse expect to perform immediately before a woman is to have regional anesthesia? Select all that apply.
Correct Answer: D
Rationale: Before a woman undergoes regional anesthesia, it is crucial for the nurse to monitor her blood pressure every 5 minutes for the first 15 minutes after the anesthesia is administered. This is because regional anesthesia can cause a sudden drop in blood pressure, known as hypotension, which can be dangerous for both the mother and the fetus. By monitoring blood pressure closely, the nurse can quickly identify any signs of hypotension and take appropriate action to prevent any complications. Assessing the fetal heart rate (Choice A) is important during labor and delivery, but it is not a necessary step immediately before regional anesthesia. Infusing 1000 cc of Ringer's lactate (Choice B) is also not a standard pre-anesthesia procedure and may not be indicated for every patient. Having the woman empty her bladder (Choice C) is a common pre-anesthesia step to prevent discomfort during the procedure, but it is not as critical as monitoring blood pressure in this situation. Overall, monitoring blood pressure every 5 minutes for the first 15 minutes after regional anesthesia is the most important action to ensure the safety and well-being of the mother and fetus during the procedure.
Question 5 of 5
The nurse is interpreting the results of a fetal blood sampling test. Which of the following reports would the nurse expect to see?
Correct Answer: D
Rationale: The correct answer is D: pH of 7.30. Fetal blood sampling is a test used to assess the well-being of the fetus during pregnancy. The pH of the fetal blood is a crucial indicator of the fetus's oxygenation status. A pH of 7.30 is within the normal range for fetal blood, indicating adequate oxygenation. Choice A, oxygen saturation of 99%, is not typically reported in fetal blood sampling tests. Oxygen saturation levels are more commonly measured in maternal blood tests. Choice B, Hgb of 11 gm/dL, is a measurement of hemoglobin levels which is not typically reported in fetal blood sampling tests. Hemoglobin levels are more relevant in assessing anemia in adults rather than in fetal blood tests. Choice C, serum glucose of 140 mg/dL, is a measurement of glucose levels which is also not typically reported in fetal blood sampling tests. Glucose levels are more commonly monitored in maternal blood tests for gestational diabetes. In summary, the correct answer is D because the pH of the fetal blood is a critical indicator of oxygenation status in the fetus, while the other choices are not typically reported in fetal blood sampling tests and are more relevant to maternal blood tests.