Author Question: A patient in labor is requesting pain medication. The nurse assesses her labor status first, ... (Read 54 times)

mckennatimberlake · **on:** Jun 27, 2018

A patient in labor is requesting pain medication. The nurse assesses her labor status first, focusing on: Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

1. The contraction pattern.
2. The amount of cervical dilatation.
3. When the labor began.
4. Whether the membranes are intact or ruptured.
5. The fetal presenting part.

Question 2

The nurse is caring for an infant who was delivered in a car on the way to the hospital and who has developed cold stress. Which finding requires immediate intervention?

1. Vasoconstriction and pallor
2. Blood glucose level of 45
3. Room-temperature IV running
4. Positioned under radiant warmer

Dnite · **Reply #1 on:** Jun 27, 2018

Answer to Question 1

1,2,5
Rationale 1: The patient should have a good contraction pattern before receiving an analgesic.
Rationale 2: The cervix should be dilated at least 3 or 4 cm for a multipara before analgesic medication is administered.
Rationale 3: This is not relevant.
Rationale 4: This has no bearing on the giving of analgesic.
Rationale 5: This is important, as the head assists in dilatation more than the buttocks do.

Answer to Question 2

3
Rationale 1: Vasoconstriction is the first physiologic response to a lowering temperature; it causes pallor.
Rationale 2: This is an adequate blood sugar in a neonate. A level lower than 40 indicates hypoglycemic.
Rationale 3: IV fluids should be warmed prior to administration and wrapped in a blanket or other insulating material to keep them warm. Room-temperature IV fluids will increase the cold stress.
Rationale 4: Radiant warmers are used to gradually increase the neonate's temperature.