ATI RN
Promoting Client Comfort During Labor and Delivery Questions
Question 1 of 5
The laboring person is using hypnosis for comfort measures. How can the nurse support the person?
Correct Answer: C
Rationale: The correct answer is C because keeping the room quiet and dimly lit promotes relaxation and helps the person stay focused during hypnosis. Bright lights and noise can be distracting and increase stress levels. Talking them through contractions (Choice A) may disrupt their concentration on hypnosis. Asking them to rate pain during contractions (Choice D) can also be disruptive and may increase anxiety.
Question 2 of 5
Nausea and vomiting are common discomforts in labor. When treating with promethazine, what must the nurse do when administering this medication?
Correct Answer: C
Rationale: The correct answer is C: Dilute before IV administration. Promethazine is a vesicant and can cause tissue damage if not properly diluted before IV administration. Diluting the medication helps reduce the risk of phlebitis and tissue irritation. Administering it subcutaneously (A) can cause pain and irritation at the injection site. Administering with an opioid (B) can increase the risk of respiratory depression. Administering promethazine in first stage labor (D) is generally safe, but diluting before IV administration is still necessary to prevent adverse effects.
Question 3 of 5
What does the nurse explain to the laboring person and partner about nitrous oxide?
Correct Answer: C
Rationale: The correct answer is C because nitrous oxide does not affect respiration like an opiate would. Nitrous oxide is a safe option for pain relief during labor because it does not depress the respiratory system. It is self-administered by the laboring person and does not require assistance from the partner. Choices A and B are incorrect because nitrous oxide does not cause respiratory depression in the newborn or the laboring person. Choice D is incorrect because the laboring person holds the mask to their face themselves.
Question 4 of 5
What are the side effects of spinal anesthesia? Select one that doesn't apply.
Correct Answer: C
Rationale: The correct answer is C: renal damage. Spinal anesthesia affects the nervous system, not the kidneys. Hypotension and respiratory depression are common side effects due to vasodilation and decreased respiratory drive. Infection can occur due to the invasive nature of the procedure. Renal damage is not a known side effect of spinal anesthesia as it does not directly affect kidney function.
Question 5 of 5
The nurse is monitoring the person's vital signs after the epidural is placed and notices a blood pressure of 80/50 mm Hg. What nursing intervention can be performed prior to the epidural placement to potentially reduce this side effect?
Correct Answer: B
Rationale: Correct Answer: B - IV fluid bolus Rationale: 1. IV fluid bolus can help increase blood volume and improve blood pressure. 2. Adequate hydration is crucial before epidural placement to prevent hypotension. 3. Other choices are not directly related to improving blood pressure in this scenario. Summary: - A: Routine use of ephedrine is not recommended as a routine prophylactic measure. - C: Insertion of indwelling urinary catheter is important for monitoring urine output but not for improving blood pressure. - D: Upright positioning may help prevent hypotension after epidural, but it's not a pre-epidural intervention to address low blood pressure.