A nurse is caring for a client who is dilated to 10 cm and pushing. Which of the following pain-management measures should the nurse identify as a safe option for the client?

Butorphanol tartrate

Pudendal block

Naloxone hydrochloride

Spinal anesthesia

Answer and Explanation

The Correct Answer is B

Rationale:

A. Butorphanol tartrate: This opioid analgesic can cause respiratory depression in the newborn if given too close to delivery. At 10 cm dilation and during pushing, it's generally too late to administer systemic opioids safely.

B. Pudendal block: A pudendal block provides localized perineal anesthesia and is safe for use during the second stage of labor when the client is fully dilated and pushing. It effectively reduces pain from stretching and pressure without affecting uterine contractions or fetal status.

C. Naloxone hydrochloride: Naloxone is not a pain-management measure; it is an opioid antagonist used to reverse opioid-induced respiratory depression. It does not provide analgesia and is not administered for pain relief during labor.

D. Spinal anesthesia: Spinal anesthesia is typically administered prior to a planned cesarean birth or late in the first stage of labor. It is not appropriate once the client is fully dilated and actively pushing, as it could delay delivery and complicate maternal positioning.

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Correct Answer is D

Explanation

Rationale:

A. Use a mechanical voice amplifier: A voice amplifier benefits clients with impaired vocal strength but does not help clients with expressive aphasia, who struggle to form or express language, not to project it audibly.

B. Provide educational materials with large print: Large print materials are helpful for clients with visual impairments but do not address language expression difficulties. Expressive aphasia requires alternative communication strategies, not visual aids.

C. Have the client's glasses brought from home: Glasses improve vision, not speech or language production. While helpful overall, they do not assist with the core issue of expressive aphasia, which is rooted in brain-language pathways.

D. Establish alternatives to verbal conversation: Using picture boards, writing tools, gestures, or communication apps helps clients express needs and ideas despite speech limitations. These strategies support more effective communication in expressive aphasia.

A. Select a vein on the back of the hand. B. Clean the site using vigorous friction. C. Use a 22-gauge catheter for insertion. D. Apply a tourniquet firmly above the insertion site.

Correct Answer is C

Explanation

Rationale:

A. Select a vein on the back of the hand: Veins on the dorsum of the hand are often more fragile and prone to infiltration or rupture in older adults. Using a more proximal site, such as the forearm, is generally safer and more stable for IV therapy.

B. Clean the site using vigorous friction: Older adults often have thinner, more delicate skin that can tear easily. While proper antiseptic technique is important, vigorous friction can cause skin trauma and should be avoided during site preparation.

C. Use a 22-gauge catheter for insertion: A 22-gauge catheter is appropriate for older adults because it minimizes vein trauma while still allowing for adequate flow rates. This size is effective for most fluids and medications while reducing the risk of vessel damage.

D. Apply a tourniquet firmly above the insertion site: Applying a tourniquet too tightly can injure fragile veins or cause them to collapse. In older adults, using minimal pressure or alternative vein-dilation methods like warm compresses is often safer.

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A nurse is caring for a client who is dilated to 10 cm and pushing. Which of the following pain-management measures should the nurse identify as a safe option for the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has expressive aphasia. Which of the following actions should the nurse take to assist the client in overcoming communication barriers?

Correct Answer is D

Explanation

A nurse is preparing to initiate IV therapy for an older adult client. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

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