A nurse is assisting in the care of a client in labor who states, "I am really afraid of giving birth," and begins crying.
The client is currently in active labor and vaginal exam reveals 7 cm dilation, 80% effacement, and 0 station. Which of the following factors of labor should the nurse identify as needing addressed at this time?
Passageway.
Passenger.
Psyche.
Powers.
The Correct Answer is C
Choice A rationale
The passageway refers to the birth canal, including the pelvis and soft tissues. While an adequate passageway is essential for labor progression, the client's current cervical dilation (7 cm) and effacement (80%) indicate that the passageway is accommodating fetal descent, and there is no direct evidence from the scenario suggesting an issue with this factor.
Choice B rationale
The passenger refers to the fetus, including its size, presentation, lie, and attitude. There is no information in the scenario to suggest any concerns with the fetus itself, such as malpresentation or distress. The focus of the client's statement is on their emotional state rather than a physical aspect of the baby.
Choice C rationale
Psyche refers to the client's psychological and emotional state during labor. The client's statement "I am really afraid of giving birth" and subsequent crying directly indicate significant fear and anxiety. This emotional distress can negatively impact labor progression by increasing catecholamine release, potentially hindering uterine contractions and increasing pain perception, thus requiring immediate attention.
Choice D rationale
Powers refer to the uterine contractions (primary power) and the mother's pushing efforts (secondary power). While effective powers are crucial for labor progression, the scenario does not provide information to suggest that the client's contractions are inadequate or that there's an issue with her ability to push. The immediate concern presented is her emotional state.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
NSAIDs (Nonsteroidal Anti-inflammatory Drugs) are commonly the first-line treatment for juvenile idiopathic arthritis (JIA). They work by inhibiting cyclooxygenase enzymes (COX-1 and COX-2), thereby reducing the production of prostaglandins, which are inflammatory mediators responsible for pain, swelling, and stiffness in the joints.
Choice B rationale
Antifungal medications are used to treat fungal infections. JIA is an autoimmune inflammatory condition, not caused by fungal pathogens. Therefore, antifungal medications have no therapeutic role in the management of juvenile idiopathic arthritis.
Choice C rationale
Antibiotics are specifically designed to combat bacterial infections. JIA is an autoimmune disease where the body's immune system mistakenly attacks its own tissues, primarily joints. It is not caused by bacteria, so antibiotics are ineffective for its treatment.
Choice D rationale
Antiviral medications are used to treat viral infections. JIA is not caused by viral pathogens but rather by an autoimmune dysfunction. Therefore, antiviral medications do not play a role in the primary management of juvenile idiopathic arthritis.
Correct Answer is B
Explanation
Choice A rationale
This interpretation incorrectly assigns the meaning of the numbers. In obstetric documentation, the first number represents dilation, the second effacement, and the third fetal station. Therefore, 3 cm for effacement and 30% for dilation is an inaccurate interpretation of standard labor documentation.
Choice B rationale
This is the correct interpretation. In standard obstetric documentation of a vaginal examination, the first number (3 cm) refers to cervical dilation, indicating the opening of the cervix. The second number (30%) refers to effacement, the thinning of the cervix. The third number (-1) indicates the fetal station, meaning the presenting part is 1 cm above the ischial spines.
Choice C rationale
This interpretation incorrectly assigns the meaning of the numbers for dilation and effacement. Additionally, a fetal station of -1 signifies the presenting part is 1 cm *above* the ischial spines, not below. This demonstrates a misunderstanding of both effacement/dilation order and station definition.
Choice D rationale
This interpretation misinterprets the fetal station. A station of -1 means the presenting part is 1 cm *above* the ischial spines, not below. This error in understanding fetal station is critical for assessing labor progression and fetal descent.
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