A nurse is assisting with the care of a client who is in the latent stage of labor and has pelvic pain with contractions.
Which of the following actions should the nurse take?
Apply fundal pressure during contractions.
Instruct the client to change positions frequently.
Tell the client to push during contractions.
Encourage the client to soak in a hot bath.
The Correct Answer is B
Explanation
B. Instruct the client to change positions frequently
Encouraging the client to move around, walk, change positions during labour can help relieve discomfort, promote optimal fetal positioning positions, or use a birthing ball can help alleviate pelvic pain and potentially facilitate the progress of labour.
Applying fundal pressure during contractions in (option A) is not necessary during the latent stage of labour. Fundal pressure is typically used in the active stage of labour to assist with the descent and positioning of the baby's head.
Telling the client to push during contractions in (option C) is not appropriate during the latent stage of labour. Pushing is typically reserved for the second stage of labour when the cervix is fully dilated.
Encouraging the client to soak in a hot bath in (option D) is not recommended during labour, particularly in the hospital setting. Immersion in hot water (e.g., a hot bath) can increase the risk of infection and is generally not recommended until after the birth of the baby
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Explanation
A. Chadwick’s sign
Chadwick's sign is a characteristic change that occurs during pregnancy, specifically in the cervix, vagina, and vulva. It is characterized by a bluish or purplish discoloration of these areas.
Chloasma in (option B) is incorrect because it is a condition characterized by the development of dark patches on the skin, commonly referred to as "mask of pregnancy." Chloasma typically affects the face, particularly the cheeks, forehead, and upper lip. It is not associated with a change in colour in the vaginal or vulvar area.
Hegar's sign in (option C) is incorrect because it is a softening of the lower uterine segment that can be felt during a pelvic examination. It is not related to the colour changes in the vaginal or vulvar area.
Ballottement in (option D) is incorrect because it is a palpation technique used during a prenatal examination to assess the position of the foetus. It involves the examiner gently pushing against the uterus and feeling a rebound or "floating" movement of the foetus. It does not involve changes in the colour of the vaginal or vulvar area.
Correct Answer is D
Explanation
Gentamicin is an aminoglycoside antibiotic that is known to have potential ototoxicity, which means it can cause damage to the inner ear and result in hearing loss. It is important for the nurse to monitor the client's hearing during gentamicin therapy and report any changes or symptoms of hearing loss promptly. Other adverse effects of gentamicin may include nephrotoxicity (kidney damage), so monitoring renal function is also essential.
Hypotension, constipation, and slurred speech are not typically associated with gentamicin use. However, it is important for the nurse to monitor the client for any adverse effects and report any concerning symptoms to the healthcare provider.
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