A client who is at full-term gestation is in active labor and complains of a cramp in her leg.
Which intervention should the practical nurse (PN) implement?
Massage the calf and foot.
Extend the leg and flex the foot.
Check the pedal pulse in the affected leg.
Elevate the leg above the heart.
None
None
The Correct Answer is B
The correct answer is B. Extend the leg and flex the foot.
Choice A rationale:
Massaging the calf and foot is not recommended as it could potentially dislodge a blood clot if one is present, which can be dangerous.
Choice B rationale:
Extending the leg and flexing the foot helps to relieve the cramp by stretching the muscles involved. This is a safe and effective method to alleviate muscle cramps.
Choice C rationale:
Checking the pedal pulse in the affected leg is important for assessing circulation but does not directly address the immediate discomfort of the cramp.
Choice D rationale:
Elevating the leg above the heart is generally used to reduce swelling and improve circulation but is not specifically effective for relieving muscle cramps.
: 3
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
Choice A rationale:
Obtaining a post-voided residual (PVR) volume is a non-invasive procedure that can be safely delegated to the unlicensed assistive personnel (UAP) to measure the amount of urine left in the bladder after urination.
Choice B rationale:
Teaching the client with fluid restrictions how to measure urine output requires specialized knowledge and is best performed by the practical nurse (PN).
Choice C rationale:
Emptying the bedside drainage unit for a client with an indwelling urinary catheter is a task that can be delegated to the UAP as it involves routine drainage and does not require advanced nursing skills.
Choice D rationale:
Irrigating an indwelling urinary catheter for a client with bladder suspension is a sterile procedure that requires nursing expertise, so it should not be assigned to the unlicensed assistive personnel.
Choice E rationale:
Transporting a urine culture sample to the laboratory is a non-complex task that can be safely delegated to the UAP to ensure timely and efficient delivery.
Correct Answer is C
Explanation
The correct answer is choicec. Ask the parents to explain what they understand about the child’s diagnosis.
Choice A rationale:
While it is important to support the parents’ decisions, this choice does not address the need for accurate information and understanding about the condition and its management.
Choice B rationale:
Hypospadias does not typically resolve on its own, and delaying surgery can lead to complications such as difficulty with urination and sexual function later in life.
Choice C rationale:
Asking the parents to explain what they understand about the child’s diagnosis ensures that they have accurate information and can make an informed decision about the timing of surgery.This approach also allows the nurse to correct any misconceptions and provide necessary education.
Choice D rationale:
Delaying surgery for hypospadias can lead to complications, including issues with urination and sexual function.It is important to address these potential risks with the parents.
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