A nurse is caring for a client who is in active labor with a fetus in the occipitoposterior position. The nurse assists the client into a hands-and-knees position. Which of the following questions should the nurse ask to evaluate the effectiveness of this intervention?
"Are you feeling relief from your pelvic pressure?"
"Do your contractions feel further apart?"
"Has your back labor improved?"
"Does that lessen your suprapubic pain?"
The Correct Answer is C
Rationale:
A. This question addresses pelvic pressure, which may not directly relate to the effectiveness of the hands-and-knees position for occipitoposterior fetal positioning.
B. The spacing of contractions is not typically affected by maternal positioning and therefore is not the most appropriate question to evaluate the effectiveness of this intervention.
C. Asking about improvement in back labor is pertinent because the hands-and-knees position can help alleviate back pain associated with occipitoposterior fetal positioning.
D. Suprapubic pain is not typically associated with occipitoposterior fetal positioning, so this question may not provide useful information regarding the effectiveness of the intervention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Applying an ice pack to the incision site is not indicated for addressing vaginal bleeding after cesarean birth and may not effectively address the underlying cause.
B. Replacing the surgical dressing is not the first action to take when assessing vaginal bleeding after cesarean birth. The priority is to evaluate the client's condition and identify the cause of the bleeding.
C. Evaluating urinary output is important to assess for urinary retention, which can contribute to uterine atony and postpartum bleeding. A full bladder can interfere with uterine contraction and lead to increased bleeding.
D. Administering a lactated Ringer's IV bolus may be indicated if the client is hypovolemic due to excessive bleeding, but it is not the first action to take. Assessing urinary output and addressing potential causes of bleeding take precedence.
Correct Answer is A
Explanation
A. To facilitate bonding between the newborn and parent. This is correct. Antibiotic ophthalmic ointment, typically used to prevent neonatal conjunctivitis, can temporarily blur the newborn's vision. Delaying its application for a short period allows the newborn to maintain eye contact with the parent during the critical bonding period immediately following birth.
B. To allow manifestations of infection to be identified. This is incorrect. The purpose of the antibiotic ointment is to prevent neonatal conjunctivitis caused by gonorrhea or chlamydia, which may not present with immediate symptoms. Delaying its application to observe for signs of infection would not be appropriate.
C. The newborn's weight is not a determining factor for delaying the instillation of antibiotic ophthalmic ointment.
D. The mode of delivery, whether vaginal or cesarean, does not affect the timing of antibiotic ophthalmic ointment instillation.
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