ATI RN
Framing Comfort During the Childbirth Process Questions
Question 1 of 5
What structure should the nurse palpate to assess fetal station?
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.
Question 2 of 5
What techniques should the nurse include for a Lamaze-trained nulliparous client? Select all that apply.
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.
Question 3 of 5
What action should the nurse take for a client experiencing tingling fingers and lightheadedness after rapid breathing?
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.
Question 4 of 5
What should the nurse do if a client falls asleep immediately after a contraction during the second stage?
Correct Answer: A
Rationale: During the second stage of labor, it is crucial for the woman to push effectively to help move the baby through the birth canal. If a client falls asleep immediately after a contraction during this stage, it is important for the nurse to awaken the woman and remind her to push. This is the correct answer because pushing during contractions helps facilitate the descent of the baby and prevents prolonged labor or potential complications. Option B: Covering the woman's perineum with a sheet is not the appropriate action in this scenario. While perineal support is important during delivery to prevent tearing, it is not the priority when the woman is not actively pushing. Option C: Assessing the woman's blood pressure and pulse may be necessary during labor, but it is not the immediate action required when the woman falls asleep after a contraction during the second stage. The priority is to ensure the progress of labor by encouraging the woman to push. Option D: Administering oxygen via a face mask is not indicated in this situation unless there are specific signs of distress or hypoxia in the mother or baby. Falling asleep after a contraction is not necessarily a sign of oxygen deprivation, so oxygen administration would not be the appropriate intervention.
Question 5 of 5
What should the nurse do if the fetal monitor shows average variability with a baseline of 142 bpm?
Correct Answer: A
Rationale: The correct answer is to provide caring labor support (Choice A). Average variability in fetal heart rate (FHR) indicates a normal fluctuation in the baby's heart rate, which is a reassuring sign of fetal well-being. The baseline heart rate of 142 bpm is within the normal range of 110-160 bpm. In this situation, the nurse should focus on providing emotional support, comfort measures, and encouragement to the laboring mother. This can help reduce anxiety, promote relaxation, and facilitate the progress of labor. Administering oxygen via face mask (Choice B) is typically indicated for fetal distress, not for average variability. Oxygen therapy is used to improve oxygenation to the fetus in cases of non-reassuring FHR patterns such as late decelerations or decreased variability. Changing the client's position (Choice C) can be beneficial in optimizing fetal oxygenation and blood flow during labor. However, in this scenario of average variability with a normal baseline heart rate, there is no immediate need to change positions unless there are other signs of fetal distress. Speeding up the client's intravenous (Choice D) is not necessary based on the information provided. Increasing the rate of IV fluids would not address the issue of average variability in FHR. It is important to monitor the IV fluids to maintain hydration and ensure proper fetal perfusion, but there is no indication to speed up the IV based solely on the FHR tracing described.