ATI RN
Promoting Client Comfort During Labor and Delivery Questions
Question 1 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.
Question 2 of 5
The nurse is monitoring a laboring patient who is using patterned breathing techniques. The patient suddenly complains of lightheadedness and tingling in her hands. What should the nurse do?
Correct Answer: B
Rationale: The correct answer is B: Instruct the patient to breathe into her cupped hands. This is because lightheadedness and tingling in hands may indicate hyperventilation from rapid breathing. Breathing into cupped hands helps rebreathe carbon dioxide, restoring balance. Choice A is incorrect as elevating legs increases blood flow to brain, worsening symptoms. Choice C is unnecessary as oxygen is not the issue. Choice D may exacerbate hyperventilation.
Question 3 of 5
Which nursing action is most appropriate for a laboring patient experiencing severe back pain due to a posterior fetal position?
Correct Answer: B
Rationale: The correct answer is B: Encourage frequent position changes. This is because changing positions can help alleviate pressure on the back and potentially help the baby rotate into a more favorable position for delivery. It is a non-invasive and supportive approach to managing back pain during labor. Offering narcotic analgesics (choice A) may provide temporary relief but does not address the underlying issue. Continuous fetal monitoring (choice C) is important but not the most immediate intervention for back pain. Immediately preparing for a cesarean delivery (choice D) is not warranted unless there are other concerning factors beyond back pain.
Question 4 of 5
The nurse is caring for a patient in transition. Which sign is most indicative that this phase of labor is occurring?
Correct Answer: B
Rationale: The correct answer is B because increased bloody show and complaints of pressure are indicative of the transition phase of labor. This phase occurs when the cervix dilates from 8 to 10 cm and contractions are strong and close together. This is a sign that the baby is moving down the birth canal. The other choices are incorrect because A describes the active phase of labor, C indicates the second stage of labor, and D reflects early labor. B is the most appropriate choice as it specifically aligns with the characteristics of the transition phase.
Question 5 of 5
A patient in early labor is feeling anxious about the labor process. Which intervention would be most effective in reducing her anxiety?
Correct Answer: A
Rationale: The correct answer is A. Explanation of the stages of labor and what to expect can help the patient understand the process, reducing uncertainty and anxiety. This empowers the patient and promotes a sense of control. Encouraging breathing techniques (B) can help manage pain but may not address the underlying anxiety. Administering sedatives (C) should be a last resort due to potential side effects. Limiting visitors (D) can help reduce stress, but addressing the patient's anxiety requires more direct intervention.