What intervention will the nurse initiate?

Correct Answer: D

Rationale: Starting an IV fluid bolus is the correct intervention in this scenario. When a pregnant woman presents with decreased fetal movement, it may indicate fetal distress, which could be due to poor oxygenation. Administering IV fluids can help increase blood flow to the fetus, improving oxygenation and potentially increasing fetal movement. Administering antibiotics (choice A) would not be the correct intervention in this situation because decreased fetal movement is not typically an indication for antibiotics. Antibiotics are typically used to treat infections, not fetal distress. Increasing oxytocin (choice B) would also not be the correct intervention. Oxytocin is a hormone that is typically used to induce or augment labor, not to address decreased fetal movement. In fact, increasing oxytocin could potentially exacerbate fetal distress. Performing fetal scalp stimulation (choice C) involves applying pressure to the fetal scalp to elicit a response in the fetus. While this can be a useful technique to assess fetal well-being, it is not the most appropriate initial intervention when decreased fetal movement is noted. Starting with IV fluids to improve oxygenation is more essential in this situation. In conclusion, starting an IV fluid bolus is the most appropriate intervention when a pregnant woman presents with decreased fetal movement. This intervention aims to improve oxygenation to the fetus, potentially addressing the underlying cause of fetal distress. Administering antibiotics, increasing oxytocin, and performing fetal scalp stimulation are not the most appropriate initial interventions in this scenario.

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: Encouraging the person to breathe however is most comfortable (Option A) is the correct choice because open glottis breathing during pushing allows for more effective pushing and reduces the risk of maternal and fetal complications. By allowing the person to breathe as they feel is best, the nurse supports the natural process of labor and helps the person to push effectively. This option also empowers the person to listen to their body and adjust their breathing pattern as needed. Option B, telling the person to hold their breath for 10 counts, is incorrect because holding the breath during pushing can increase intra-abdominal pressure, decrease blood flow to the uterus, and lead to decreased oxygen supply to the baby. This can result in fetal distress and maternal exhaustion. Encouraging breath-holding can also lead to ineffective pushing and prolong the labor process. Option C, explaining that open glottis pushing is not effective, is incorrect because open glottis pushing is a widely accepted technique that has been shown to reduce the risk of fetal distress, perineal trauma, and maternal exhaustion. By coaching the person to use open glottis breathing, the nurse can help them to push more effectively and efficiently. Option D, discussing that the health-care provider would not allow them to use that breathing, is incorrect because open glottis breathing is a safe and effective technique for pushing during labor. It is important for the nurse to support the person's chosen breathing technique and provide guidance on how to push effectively using open glottis breathing. By working together with the person and their healthcare provider, the nurse can help to ensure a safe and positive birthing experience.

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.