A nurse is caring for a client who is in labor and is reporting intense pain during contractions. The client has no previous knowledge of nonpharmacological comfort measures. Which of the following nursing interventions should the nurse implement?
Slow paced breathing
Biofeedback
Self hypnosis
Acupuncture
The Correct Answer is A
The correct answer is A. Slow-paced breathing
A. Slow-paced breathing is a nonpharmacological comfort measure that involves taking slow, deep breaths to promote relaxation and reduce anxiety. It can be an effective technique for managing pain during contractions.
B. Biofeedback involves the use of electronic monitoring to provide feedback about physiological processes, and it is not typically used as a primary nonpharmacological comfort measure for labor pain.
C. Self-hypnosis is a relaxation technique that involves guided imagery and focused concentration to promote relaxation and reduce pain. However, it may require some previous knowledge or practice, and in the context of this scenario, slow-paced breathing may be a more immediate and accessible option.
D. Acupuncture involves the insertion of needles into specific points on the body to stimulate energy flow. While acupuncture can be effective for pain management, it may not be readily available in all labor settings, and slow-paced breathing is a more universally applicable option.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Placing a rolled towel beneath one of the client's hips may be helpful to tilt the client and alleviate pressure, but it is not the first action.
Choice B Reason:
Applying internal upward pressure to the presenting part using two gloved fingers is appropriate. This maneuver, known as "manual elevation of the presenting part," helps lift the presenting part off the prolapsed cord, preventing compression and maintaining blood flow to the fetus. This action should be performed while waiting for additional assistance and interventions.
Choice C Reason:
Administering oxygen is important for the well-being of the fetus, but the immediate focus is on relieving pressure on the umbilical cord.
Choice D Reason:
Increasing the infusion rate may be necessary later, but the immediate priority is to address the prolapsed cord and ensure fetal oxygenation.
4.A nurse is providing discharge teaching to the parents of a newborn about car seat safety. Which of the following instructions should the nurse Include?
A. Place the shoulder harness in the slots above the newborn's shoulders.
B. Place the retainer clip at the level of the newborn's armpits.
C. Place the newborn at a 60° angle in the car seat.
D. Place the newborn in a blanket before securing them in the car seat.
Explanation
The correct answer is choice B
Choice A Reason:
Placing the shoulder harness in the slots above the newborn's shoulders is incorrect. The harness should be threaded through the slots at or below the baby's shoulders to provide proper protection.
Choice B Reason:
Placing the retainer clip at the level of the newborn's armpits is correct. This is a critical safety measure to ensure that the harness straps are positioned correctly on the newborn. Placing the retainer clip at the level of the armpits helps secure the harness straps over the baby's shoulders and prevents them from slipping off.
Choice C Reason:
Placing the newborn at a 60° angle in the car seat is not a standard recommendation. The car seat should be installed according to the manufacturer's instructions, and the baby should be placed in a semi-reclined position, typically at a 45° angle, to ensure proper support for the newborn's head and airway.
Choice D Reason:
Placing the newborn in a blanket before securing them in the car seat is not recommended. Extra padding, including bulky clothing or blankets, should not be placed under the harness straps as it can compromise the effectiveness of the restraint system. The baby should be dressed in thin layers, and if additional warmth is needed, a blanket can be placed over the baby after securing them in the car seat.
Correct Answer is A
Explanation
Choice A Reason:
"You can miss your period for several other reasons. Describe your typical menstrual cycle." This response acknowledges that a missed period can result from various factors other than pregnancy, such as stress, changes in weight, hormonal fluctuations, or certain medical conditions. Understanding the client's typical menstrual cycle can help the nurse gather more information about potential reasons for the late period.
Choice B Reason:
"If you have been sexually active and haven't used protection, it is likely that you are pregnant. “This response assumes pregnancy without exploring other possibilities or the client's individual situation.
Choice C Reason:
"Let's check to see if you have any other signs of pregnancy. Have you noticed any abdominal enlargement yet?" While considering other signs of pregnancy is reasonable, focusing on abdominal enlargement may not be the most accurate early indicator, and it's essential to explore a broader range of symptoms.
Choice D Reason:
"Because you have missed your period, you should try taking a home pregnancy test before you start worrying. "While suggesting a home pregnancy test is reasonable, it may be more beneficial to gather additional information about the client's menstrual cycle and potential symptoms before jumping directly to a test.
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