What can the nurse offer the laboring person to help with relaxation and reducing anxiety?

Correct Answer: A

Rationale: A: Lavender oil is a commonly used essential oil known for its calming and relaxing properties. The scent of lavender has been shown to reduce anxiety and promote relaxation, making it an effective option for laboring individuals looking to manage stress and discomfort during labor. B: An epidural is a form of regional anesthesia commonly used during labor to provide pain relief. While an epidural can help manage pain, it does not specifically target relaxation or anxiety reduction, making it a less suitable option for individuals looking for holistic approaches to labor support. C: Nalbuphine hydrochloride (Nubain) is an opioid analgesic used for pain management during labor. While it can help reduce pain, opioids can have side effects such as drowsiness, nausea, and potential respiratory depression, which may not align with the goal of promoting relaxation and reducing anxiety. D: A cold rag is a non-pharmacological comfort measure that can provide temporary relief from heat or discomfort during labor. While it may offer some physical comfort, it does not address the emotional and psychological aspects of anxiety and relaxation that lavender oil can target effectively. In conclusion, lavender oil is the most appropriate choice among the options provided as it specifically targets relaxation and anxiety reduction, making it a suitable holistic approach for labor support.

Correct Answer: A

Rationale: Hydroxyzine is the correct answer because it is an antihistamine that also has anxiolytic properties. It acts as a central nervous system depressant, which helps to reduce anxiety and create a sense of calm in individuals. Hydroxyzine works by blocking certain neurotransmitters in the brain, specifically histamine receptors, which leads to its anxiolytic effects. Option B, fentanyl, is a potent opioid analgesic used for pain management, not anxiety relief. Fentanyl works by binding to opioid receptors in the brain and spinal cord to decrease pain perception, but it does not have anxiolytic properties. Option C, codeine, is another opioid analgesic commonly used for pain relief. Like fentanyl, codeine works by binding to opioid receptors in the brain to alleviate pain, but it does not have the same anxiolytic effects as hydroxyzine. Option D, morphine, is also an opioid analgesic used for pain management. Morphine acts on the central nervous system to decrease pain sensation by binding to opioid receptors, similar to codeine and fentanyl. However, it does not possess anxiolytic properties like hydroxyzine. In conclusion, hydroxyzine is the correct answer as it is specifically designed to relieve anxiety and promote a sense of calm, unlike the other options which are opioids primarily used for pain relief.

Correct Answer: A

Rationale: After administering fentanyl, the nurse explains the need to monitor the patient's oxygen saturation because fentanyl is a potent opioid analgesic that can cause respiratory depression as a side effect. Monitoring oxygen saturation is crucial to ensure the patient is breathing adequately and receiving enough oxygen. This is the priority after administering any opioid medication to prevent respiratory complications. Choice B is incorrect because inserting a Foley catheter is not directly related to administering fentanyl. Foley catheter insertion is typically indicated for urinary retention or monitoring urine output, which is not a common concern after fentanyl administration. Choice C is incorrect because monitoring for vaginal bleeding is not relevant to administering fentanyl. Vaginal bleeding is more commonly associated with gynecological issues or childbirth, not opioid analgesic administration. Choice D is incorrect because checking the cervix is also not necessary after administering fentanyl. Cervical exams are typically done for gynecological reasons or during labor, not in relation to opioid analgesic administration. In summary, monitoring oxygen saturation is essential after administering fentanyl to ensure the patient's respiratory status is stable. The other choices are incorrect because they are not directly related to the effects or side effects of fentanyl.

Correct Answer: A

Rationale: After epidural catheter insertion, the nurse's responsibility is to monitor vital signs every 5 to 15 minutes. This is the correct answer because monitoring vital signs is crucial to ensure the laboring person's safety and detect any potential complications related to the epidural anesthesia. Choice B, intermittent FHR monitoring, is incorrect because FHR monitoring is typically done continuously or periodically during labor to assess the baby's well-being, not specifically after epidural catheter insertion. Intermittent monitoring may still be necessary, but it is not the immediate responsibility after epidural insertion. Choice C, providing the laboring person a meal, is incorrect because it is generally not recommended to eat a heavy meal during labor, especially after epidural insertion. The laboring person may be restricted to clear liquids or ice chips to prevent aspiration in case emergency intervention is needed. Choice D, instructing the laboring person to get out of bed to use the restroom, is incorrect because after epidural insertion, the laboring person may have decreased sensation and mobility in their lower body. It is unsafe to ask them to get out of bed without assistance due to the risk of falls or injuries. In conclusion, monitoring vital signs every 5 to 15 minutes is the nurse's responsibility after epidural catheter insertion to ensure the laboring person's safety and well-being.

Correct Answer: C

Rationale: In the early phase of labor, the primary goal of nursing care is to promote relaxation and provide comfort measures (Choice C). This is because during this stage, the cervix is dilating and effacing, and contractions are becoming more regular and intense. Providing comfort measures such as massage, positioning changes, breathing techniques, and relaxation techniques can help the laboring woman cope with the pain and discomfort of contractions, as well as reduce anxiety and stress. Administering pain medication (Choice A) may be necessary later in labor if the woman requests it or if labor becomes too intense, but it is not the primary goal in the early phase. Nurses should first focus on non-pharmacological comfort measures to help the woman cope with labor pain. Monitoring fetal heart rate continuously (Choice B) is important throughout labor to assess the well-being of the fetus, but it is not the primary goal in the early phase. Fetal heart rate monitoring should be ongoing, but it does not take precedence over providing comfort and support to the laboring woman. Preparing for imminent delivery (Choice D) is also important but is not the primary goal in the early phase of labor. While it is essential to be prepared for delivery at any time, the early phase is typically a longer period where the focus is on providing comfort and support to the woman as labor progresses.