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 A
Explanation
A.
Rationale:
A. Excessive crying:
Correct answer. Neonatal abstinence syndrome (NAS) often presents with irritability, inconsolable crying, and difficulty soothing.
B. Decreased muscle tone: NAS can cause hypertonia or increased muscle tone rather than decreased muscle tone.
C. Absent Moro reflex: NAS may cause hyperactive Moro reflex rather than absent.
D. Diminished deep tendon reflexes: NAS can cause hyperactive deep tendon reflexes rather than diminished.
Correct Answer is C
Explanation
Rationale:
A. Airborne precautions are used for diseases transmitted by airborne droplet nuclei smaller than 5 microns, such as tuberculosis. MRSA is not transmitted via airborne route.
B. Protective environment is used for clients who are immunocompromised, such as those undergoing bone marrow transplantation. It is not indicated for MRS
A.
C. Contact precautions are indicated for MRSA, as it is primarily transmitted through direct or indirect contact with an infected individual or contaminated environment.
D. Droplet precautions are used for diseases transmitted by large droplets (>5 microns), such as influenza or pertussis. MRSA is not transmitted via droplets.
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