Author Question: Which comfort measure should the nurse use to assist the laboring woman to relax? a. Keep the ... (Read 83 times)

KWilfred · **on:** Jun 27, 2018

Which comfort measure should the nurse use to assist the laboring woman to relax?

a. Keep the room lights lit so that the patient and her coach can see everything.
b. Offer warm, wet cloths to use on the patient's face and neck.
c. Palpate her filling bladder every 15 minutes.
d. Recommend frequent position changes.

Question 2

An infant with tetralogy of Fallot is having a hypercyanotic episode. Which of the following nursing interventions should the nurse implement? Select all that apply.

1. Place the child in knee-chest position.
2. Draw blood for a serum hemoglobin.
3. Administer oxygen.
4. Administer morphine and propranolol intravenously as ordered.
5. Administer Benadryl as ordered.

manuelcastillo · **Reply #1 on:** Jun 27, 2018

Answer to Question 1

D
Feedback
A Soft, indirect lighting is more soothing than irritating bright lights.
B Women in labor become hot and perspire. Cool cloths are much better
C A full bladder intensifies labor pain. The bladder should be emptied every 2
hours.
D Frequent maternal position changes reduce the discomfort from constant pressure
and promote fetal descent.

Answer to Question 2

1; 3; 4
Rationale:
1. When an infant with tetralogy of Fallot has a hypercyanotic episode, interventions should be geared toward decreasing the pulmonary vascular resistance. Therefore, the nurse would place the child in the knee-chest position (to decrease venous blood return from the lower extremities) and administer oxygen, morphine, and propranolol (to decrease the pulmonary vascular resistance).
2. The nurse would not draw blood until the episode had subsided, because unpleasant procedures are postponed.
3. When an infant with tetralogy of Fallot has a hypercyanotic episode, interventions should be geared toward decreasing the pulmonary vascular resistance. Therefore, the nurse would place the child in the knee-chest position (to decrease venous blood return from the lower extremities) and administer oxygen, morphine, and propranolol (to decrease the pulmonary vascular resistance).
4. When an infant with tetralogy of Fallot has a hypercyanotic episode, interventions should be geared toward decreasing the pulmonary vascular resistance. Therefore, the nurse would place the child in the knee-chest position (to decrease venous blood return from the lower extremities) and administer oxygen, morphine, and propranolol (to decrease the pulmonary vascular resistance).
5. Benadryl is not appropriate for this child.