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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Gestational diabetes mellitus is not a contraindication for a contraction stress test. In fact, clients with gestational diabetes may require additional fetal monitoring due to the increased risk of fetal complications.
B. A previous classical incision, also known as a vertical uterine incision, increases the risk of uterine rupture during labor, making a contraction stress test contraindicated.
C. A previous stillbirth is not a contraindication for a contraction stress test. In fact, it may prompt additional fetal monitoring to assess for potential complications in subsequent pregnancies.
D. A nonreactive nonstress test may indicate the need for further evaluation with a contraction stress test; it is not a contraindication in itself.
Correct Answer is C
Explanation
Rationale:
A. Using a 21-gauge needle may be too large for a newborn, increasing the risk of discomfort and tissue damage.
B. Inserting the needle at a 45° angle may not be appropriate for intramuscular injections in newborns. The preferred angle is typically 90°.
C. Administering the injection into the vastus lateralis muscle is the recommended site for hepatitis B vaccination in newborns. This site is located on the anterior lateral aspect of the thigh and provides good muscle mass for injection.
D. Vigorously massaging the site following the injection is not recommended as it may increase discomfort and tissue trauma. Instead, gentle pressure can be applied to the site to help reduce discomfort.
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