What complications require monitoring for aspiration?

Correct Answer: A

Rationale: Aspiration is a serious complication that occurs when food, liquids, or stomach contents are inhaled into the lungs instead of being swallowed into the esophagus. This can lead to pneumonia, lung abscess, or even respiratory failure. Neurologic dysfunction (choice A) is the correct answer because conditions such as stroke, seizures, or impaired consciousness can lead to difficulty swallowing, increasing the risk of aspiration. Patients with neurologic dysfunction may have impaired gag reflexes or difficulty coordinating their swallowing mechanism, making them more prone to aspiration. Kidney failure (choice B) is incorrect because it does not directly relate to the risk of aspiration. While kidney failure can lead to electrolyte imbalances or fluid overload, which may impact a patient's overall health, it does not specifically increase the risk of aspiration. Gestational diabetes (choice C) is also incorrect as it is a condition related to high blood sugar levels during pregnancy. While gestational diabetes can have complications such as macrosomia (large baby) or birth complications, it does not directly impact the risk of aspiration. Postpartum hemorrhage (choice D) is not directly related to the risk of aspiration. Postpartum hemorrhage is excessive bleeding following childbirth and can lead to complications such as shock or organ failure, but it does not increase the risk of aspiration. In conclusion, monitoring for aspiration is crucial in patients with neurologic dysfunction as they are at a higher risk due to impaired swallowing mechanisms. It is important to assess these patients for signs of aspiration such as coughing while eating or drinking, altered voice quality, or respiratory distress. Regular monitoring and interventions can help prevent aspiration and its potential complications.

Correct Answer: B

Rationale: To assess fetal station, the nurse should palpate the ischial spines. The ischial spines are bony landmarks in the pelvis that indicate the level of the fetal head in relation to the mother's pelvis. Palpating the ischial spines helps determine the descent of the fetal head during labor and assess the progress of labor. The sacral promontory is not the correct structure to palpate to assess fetal station. The sacral promontory is located at the top of the sacrum and is not a reliable indicator of fetal station. Palpating the sacral promontory may provide information about the position of the baby's head in relation to the mother's pelvis but is not as accurate as palpating the ischial spines. The cervix is not the correct structure to palpate to assess fetal station. The cervix is the lower part of the uterus that opens during labor to allow the baby to pass through the birth canal. Palpating the cervix can help determine the dilation and effacement of the cervix but does not provide information about the descent of the fetal head in relation to the mother's pelvis. The symphysis pubis is not the correct structure to palpate to assess fetal station. The symphysis pubis is the bony joint at the front of the pelvis where the two pubic bones meet. Palpating the symphysis pubis does not provide information about the descent of the fetal head in relation to the mother's pelvis. It is important to palpate the ischial spines for an accurate assessment of fetal station during labor.

Correct Answer: C

Rationale: During labor, intense back pain is often associated with the baby being in the occiput posterior position. This means that the baby's head is facing the mother's abdomen, with the back of the head against the mother's spine. Choice A, Mentum anterior, refers to the baby's chin being positioned towards the mother's spine. This position is actually ideal for childbirth as it allows for easier passage through the birth canal and is not typically associated with intense back pain during contractions. Choice B, Sacrum posterior, refers to the baby's back being positioned towards the mother's spine. While this position can cause back pain during labor, it is not typically described as intense and is less common than occiput posterior. Choice D, Scapula anterior, refers to the baby's shoulder blade being positioned towards the mother's spine. This position is not typically associated with intense back pain during contractions, as the baby's head position is more critical in determining the experience of back pain during labor. In summary, the correct answer is C (Occiput posterior) because this position is most likely to cause intense back pain during contractions due to the baby's head pressing against the mother's spine. Choices A, B, and D are incorrect because they do not align with the typical presentation of intense back pain during labor associated with occiput posterior positioning.

Correct Answer: C

Rationale: C: Muscle relaxation is a key technique that should be included for a Lamaze-trained nulliparous client. This technique involves teaching the client how to relax their muscles during labor, which can help reduce pain and tension. Lamaze focuses on using breathing techniques and muscle relaxation to cope with labor pain, making it an essential component for a nulliparous client who is new to childbirth. A: Hypnotic suggestion is not typically a technique included in Lamaze training. While some individuals may find hypnosis helpful for pain management during labor, it is not a standard component of Lamaze education. Therefore, this technique would not be recommended for a Lamaze-trained nulliparous client. B: Rhythmic chanting is also not a technique commonly included in Lamaze training. While some women may find chanting or other forms of vocalization helpful during labor, it is not a primary focus of Lamaze techniques. Therefore, this would not be a necessary technique to include for a Lamaze-trained nulliparous client. D: Abdominal massage is not a standard technique taught in Lamaze training. While massage can be a helpful form of pain relief during labor, specifically focusing on the abdominal area may not be a primary focus of Lamaze education. Therefore, this technique would not be essential for a Lamaze-trained nulliparous client.

Correct Answer: B

Rationale: The correct action for the nurse to take for a client experiencing tingling fingers and lightheadedness after rapid breathing is to have the woman breathe into a bag (Choice B). This symptom presentation is indicative of hyperventilation, where the client is breathing too quickly, resulting in decreased levels of carbon dioxide in the blood. Breathing into a bag helps the client re-breathe the exhaled carbon dioxide, which can help restore the balance of gases in the blood and alleviate symptoms. Assessing the blood pressure (Choice A) may not be the most immediate action to take in this situation. While monitoring blood pressure is important in assessing overall health, it may not directly address the symptoms of tingling fingers and lightheadedness associated with hyperventilation. Turning the woman onto her side (Choice C) is not the most appropriate action for a client experiencing hyperventilation. While this action may be helpful in other situations, such as preventing aspiration in a client who is vomiting, it does not address the underlying cause of hyperventilation. Checking the fetal heart rate (Choice D) is not necessary in this situation unless the client is pregnant. In the context of hyperventilation, the priority is to address the client's symptoms and help restore normal breathing patterns. Checking the fetal heart rate would not directly address the client's symptoms of tingling fingers and lightheadedness.