A nurse is caring for a client who is in labor and whose fetus is in the right occiput posterior position. The client is dilated to 8 cm and reports back pain. Which of the following actions should the nurse take?

Apply sacral counterpressure.

Perform transcutaneous electrical nerve stimulation (TENS)

Initiate slow-paced breathing.

Assist with biofeedback

Answer and Explanation

The Correct Answer is A

Choice A Reason:

Applying sacral counterpressure is appropriate. In the right occiput posterior position, the fetal head is positioned towards the mother's back, leading to increased pressure on the sacral are

A. Applying sacral counterpressure can help alleviate back pain during contractions.

Choice B Reason:

Performing transcutaneous electrical nerve stimulation (TENS) is inappropriate. While TENS can be used for pain relief in labor, applying sacral counterpressure is a more specific intervention for back pain related to fetal positioning.

Choice C Reason:

Initiating slow-paced breathing is inappropriate. While slow-paced breathing is a coping mechanism during contractions, it may not specifically address the back pain associated with the fetus in the right occiput posterior position.

Choice D Reason:

Assisting with biofeedback is inappropriate. Biofeedback is not a standard intervention for managing back pain during labor, especially in the context of fetal positioning. Sacral counterpressure is a more direct approach for this situation.

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Correct Answer is A

Explanation

The correct answer is A. Decreased platelet count.

A. Decreased platelet count: ITP is characterized by a decreased platelet count. It is an autoimmune disorder where the immune system attacks and destroys platelets, leading to a reduction in the number of circulating platelets.

B. Increased erythrocyte sedimentation rate (ESR): ITP is not typically associated with an increased ESR. ESR is a marker of inflammation, and ITP is primarily a disorder of platelet destruction rather than inflammation.

C. Decreased megakaryocytes: ITP is often associated with normal or increased numbers of megakaryocytes in the bone marrow. Megakaryocytes are the precursor cells for platelets, and their increased presence indicates that the bone marrow is trying to produce more platelets to compensate for the destruction occurring in the bloodstream.

D. Increased WBC: ITP primarily affects platelet counts and does not necessarily lead to an increased white blood cell (WBC) count. The primary concern in ITP is the risk of bleeding due to low platelet levels.

A. Administer oxygen to the client B. Turn the client onto her side C. Increase the client's IV fluid infusion rate D. Palpate the client's uterus

Correct Answer is B

Explanation

The correct answer is B. Turn the client onto her side.

A. Administering oxygen to the client is a reasonable intervention in the presence of late decelerations, but turning the client onto her side is the priority action to relieve potential compression of the vena cava and improve fetal oxygenation.

B. Turning the client onto her side is the correct first action.

Late decelerations are often associated with uteroplacental insufficiency. Changing the client's position, especially to the left lateral position, can help alleviate pressure on the vena cava, improving blood flow to the uterus and fetal oxygenation.

C. Increasing the client's IV fluid infusion rate may be considered, but it is not the first action to address late decelerations. Positioning changes should be initiated promptly.

D. Palpating the client's uterus is an assessment that may be done, but it is not the first action when late decelerations are observed. Positioning changes take precedence.

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A nurse is caring for a client who is in labor and whose fetus is in the right occiput posterior position. The client is dilated to 8 cm and reports back pain. Which of the following actions should the nurse take?

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