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 B

Explanation

The correct answer is B.

A. Place warm, moist packs on the breasts: Warm, moist packs can increase blood flow and may actually stimulate milk production. This is not an appropriate intervention for lactation suppression.

B. Apply cabbage leaves to the breasts: This is the correct intervention. Cabbage leaves have been traditionally used to help reduce engorgement and suppress lactation. The mechanism is not fully understood, but it is believed that compounds in cabbage may help decrease milk supply.

C. Wear a loose-fitting bra: Wearing a loose-fitting bra can help reduce friction and discomfort, but it is not a specific intervention for lactation suppression.

D. Put green teabags on the breast: Green teabags are not commonly recommended for lactation suppression. Cabbage leaves are more widely accepted for this purpose.

A. Large for gestational age B. Hyperglycemia C. Bradypnea D. Vomiting

Correct Answer is D

No explanation

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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?

Nursing Test Bank

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