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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. "I prefer to leave the lights off when I am changing my clothes.": This statement suggests discomfort with the appearance of the body after surgery and a desire to hide it, which reflects an altered body image. Avoiding visual exposure is a common coping mechanism for those struggling with physical changes.
B. "I am ready to join a breast cancer support group.": Willingness to participate in a support group indicates acceptance and proactive coping. It reflects psychological adaptation rather than body image disturbance.
C. "I want to have reconstructive surgery as soon as I can.": Expressing a desire for reconstruction shows future-oriented thinking and a readiness to restore body image, not necessarily an inability to accept the current state.
D. "I understand that my scars will eventually fade.": This statement demonstrates acceptance and understanding of the healing process, indicating a realistic and healthy perception of body changes.
Correct Answer is A
Explanation
Rationale:
A. Assist the client to ambulate: Ambulation is encouraged after a laparoscopic cholecystectomy to stimulate peristalsis and help relieve abdominal distention caused by retained gas from insufflation during the procedure. It promotes bowel movement and absorption of gas, improving comfort.
B. Prepare the client for a paracentesis: Paracentesis is used to remove fluid from the peritoneal cavity, typically in clients with ascites or severe fluid retention. Abdominal distention after this procedure is usually due to gas, not fluid.
C. Insert a rectal suppository: Suppositories may stimulate bowel movements but are not the first-line intervention for post-laparoscopic gas-related distention. Encouraging natural movement through ambulation is more effective and less invasive initially.
D. Place the client in the prone position: The prone position is not typically used for relieving abdominal distention. It may cause discomfort and does not aid in gas movement through the intestines as effectively as upright or walking positions.
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