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.
The Correct Answer is C
The correct answer is: Choice C - Check the pedal pulse in the affected leg.
Rationale:
- Choice A: Massage the calf and foot: While massage can be helpful for relieving muscle cramps in some cases, it is not the most appropriate first step in this situation. A leg cramp during labor could be a sign of a more serious condition, such as a blood clot (deep vein thrombosis or DVT). Massaging the area could potentially dislodge the clot and cause a pulmonary embolism (PE), a life-threatening condition.
- Choice B: Extend the leg and flex the foot: This maneuver may stretch the calf muscle and temporarily relieve the cramp, but it doesn't address the underlying cause. Additionally, extending the leg completely could be uncomfortable for the woman in labor.
- Choice C: Check the pedal pulse in the affected leg: This is the most crucial step. A weak or absent pedal pulse in the affected leg could be a strong indicator of DVT. Checking the pulse allows the nurse to assess for potential complications and escalate care if necessary.
- Choice D: Elevate the leg above the heart: Elevation can be helpful for reducing swelling and improving circulation, but it's not the primary concern in this case. Checking the pulse takes priority to assess for circulatory compromise.
Summary:
Leg cramps during labor can be caused by various factors, but it's essential to rule out more serious conditions like DVT. Checking the pedal pulse is the initial step to assess circulation and identify potential complications. If the pulse is weak or absent, the nurse should notify the healthcare provider immediately for further evaluation and treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice c. Tell the UAP to continue because the unconscious client is positioned safely.
Choice A rationale:
Enrolling the UAP in a hospital education class on conducting safe client care is a proactive measure, but it is not an immediate action required in this scenario. The UAP is already performing the task correctly.
Choice B rationale:
Praising the UAP for doing the oral hygiene and encouraging family participation is positive reinforcement, but it does not address the immediate task at hand. The focus should be on ensuring the client’s safety during the procedure.
Choice C rationale:
Telling the UAP to continue because the unconscious client is positioned safely is the correct action. The side-lying position with an emesis basin under the chin is appropriate for an unconscious client as it helps prevent aspiration by allowing secretions to drain out of the mouth.
Choice D rationale:
Stopping the procedure and telling the UAP to place the client in a Fowler’s position is incorrect. The Fowler’s position is not suitable for oral hygiene in an unconscious client as it increases the risk of aspiration.
Correct Answer is C
Explanation
The correct answer is choice C. Consult with the client about the reasons for his refusal to be weighed.
Choice A rationale:
Including "Noncompliance”. as a priority problem in the client's plan of care assumes the client's refusal to be weighed is intentional and willfully disobedient. This may not be the case, and labeling the client as noncompliant could create a negative atmosphere, hindering effective communication and care.
Choice B rationale:
Advising the UAP to re-attempt the daily weight after the client eats breakfast does not address the underlying reason for the client's refusal. Additionally, there is no evidence suggesting that weighing the client after breakfast will improve the situation.
Choice C rationale:
Consulting with the client about the reasons for his refusal to be weighed is the most appropriate action. Open communication with the client can help identify any concerns or fears related to the weighing process. By understanding the client's perspective, the healthcare team can work together to find a solution that ensures the client's cooperation with the weight monitoring.
Choice D rationale:
Calculating the client's weight based on the 24-hour fluid intake and output is not a reliable method for obtaining an accurate weight measurement. Fluid volume overload can lead to fluid retention and may not accurately reflect the client's true weight.
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